Palliative Care Medical and Health News Headlines

Preparing for palliative medicine; evaluation of an education programme for fourth year medical undergraduates.

Palliat Med. 2008 Sep;22(6):687-692

Authors: Mason S, Ellershaw J

Prompted by directives from the GMC, 'care of the dying' is identified as 'core curricula' for undergraduate medical education. However, there are many technical and interpersonal challenges faced in learning the practice of palliative medicine. Accordingly, the design and delivery of education programmes need to be both carefully considered and evaluated. Using Bandura's Social Cognitive Theory as a driver, appropriate methodology for evaluating a novel education programme in palliative medicine was drafted. A pre- and post-survey of an education programme and palliative care placement for fourth year medical undergraduate students from Liverpool University (n = 216) was completed using a composite questionnaire containing; i) Self-efficacy in Palliative Care Scale (SEPC) and ii) Thanatophobia Scale. Both scales have shown reliability and validity within the sample population. Additionally, a randomly selected Focus Group was conducted to provide qualitative information on the students' experience. A total of 139 pre- and post-questionnaires (64%) were completed. Analysis identified significant improvements in perceived efficacy (SEPC Communication t = -16.41, P < 0.001; SEPC Patient Management t = -22.31, P < 0.001; SEPC Multidisciplinary Teamwork t = -15.56, P < 0.001). Significant improvements in thanatophobia were also recorded (z = -7.51, P < 0.001) although some interesting anomalies were noted. This study demonstrates that considered and appropriately structured clinical education has been shown to significantly improve students' belief in their ability to practice palliative medicine and to improve their attitude towards care. In accordance with the study's theoretical driver, it is reasonable to propose that the engaged active learning will have a positive effect on the future care of dying patients.

PMID: 18715966 [PubMed - as supplied by publisher]

Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review.

Palliat Med. 2008 Sep;22(6):693-701

Authors: Zhao I, Yates P

The aim is to review the published scientific literature for studies evaluating non-pharmacological interventions for breathlessness management in patients with lung cancer. The following selection criteria were used to systematically search the literature: studies were to be published research or systematic reviews; they were to be published in English and from 1990 to 2007; the targeted populations were adult patients with dyspnoea/breathlessness associated with lung cancer; and the study reported on the outcomes from use of non-pharmacological strategies for breathlessness. This review retrieved five studies that met all inclusion criteria. All the studies reported the benefits of non-pharmacological interventions in improving breathlessness regardless of differences in clinical contexts, components of programmes and methods for delivery. Analysis of the available evidence suggests that tailored instructions delivered by nurses with sufficient training and supervision may have some benefits over other delivery approaches. Based on the results, non-pharmacological interventions are recommended as effective adjunctive strategies in managing breathlessness for patients with lung cancer. In order to refine such interventions, future research should seek to explore the core components of such approaches that are critical to achieving optimal outcomes, the contexts in which the interventions are most effective, and to evaluate the relative benefits of different methods for delivering such interventions.

PMID: 18715967 [PubMed - in process]

Population-based study of dying in hospital in six European countries.

Palliat Med. 2008 Sep;22(6):702-10

Authors: Cohen J, Bilsen J, Addington-Hall J, Löfmark R, Miccinesi G, Kaasa S, Onwuteaka-Philipsen B, Deliens L

This study examined the proportion of deaths taking place in hospitals in six European countries in relation to demographic, epidemiologic and healthcare factors. Retrospective analyses were performed on a database integrating death certificate data of all deaths in 2002 in Sweden and 2003 in Belgium, England, Scotland, the Netherlands and Wales (N = 891,780). Data were linked with regional healthcare statistics. Of all deaths, from 33.9% (the Netherlands) to 62.8% (Wales) occurred in hospital. Large country differences in hospital deaths were partly explained by the availability of care home and hospital beds. Differences between countries were strikingly large in older patients and cancer patients. Older patients had a higher probability of dying in hospital in Sweden, Scotland, England and Wales than in Flanders and, in particular, in the Netherlands. Cancer patients often died in hospitals in Sweden but less frequently so in the Netherlands and England. Country differences in the proportion of patients dying in hospital are only partly the result of differences in health care provision, and are in particular larger for certain patient categories, suggesting country-specific end-of-life practices in these categories. These findings can contribute to rational public health policies aimed at reducing hospital deaths.

PMID: 18715968 [PubMed - in process]

Development and validation of a prognostic scale for use in patients with advanced cancer.

Palliat Med. 2008 Sep;22(6):711-7

Authors: Stone P, Kelly L, Head R, White S

The aim of this study was to develop a new prognostic indicator to help predict survival in advanced cancer patients more accurately. Data on 329 patients obtained from a multi-centre study in London were analysed. A multifactorial Cox regression model was applied and validated using bootstrapping techniques. Predictive scores were calculated and used to produce a new prognostic index. The value of the index in predicting 14-day survival was then assessed. Four variables were found to be associated with worse survival: primary lung cancer, secondary liver cancer, raised C-Reactive protein and poor performance status (ECOG 4). Survival curves showed that patients designated as 'high' risk by the resulting index had significantly shorter survival than those designated as 'low' risk. A high score on the newly derived prognostic index is associated with poorer survival, but its clinical utility is limited by the relatively low predictive probability of the score.

PMID: 18715969 [PubMed - in process]

Validation of a consciousness level scale for palliative care.

Palliat Med. 2008 Sep;22(6):724-9

Authors: Gonçalves F, Bento M, Alvarenga M, Costa I, Costa L

The main objective of this study is to validate a Consciousness Scale for palliative care. The scale was named Consciousness Scale for palliative care (CSPC). The validation had two phases: 1) face validity - the scale was assessed by seven healthcare professionals, both doctors and nurses, experienced in palliative care; 2) reliability and construct validity - performed by four investigators, two nurses and two doctors. The construct validation was performed by comparing the CSPC with a Visual Analogue Scale (VAS) of 100 mm, anchored in the terms 'awake' and 'unarousable', and then with the Glasgow Coma Scale (GCS). In this study, all four observers completed 44 periods of observation relative to 38 patients resulting in a total of 176 observations. In the phase of face validation, there were no discrepancies in relation to the issue: the scale provides measures for measurement; the scale can be useful to clinical practice; the scale can improve communication among professionals and the scale is easy to use. As a measure of internal consistency, Cronbach's alpha was found to be very high (0.99). The inter-rater reliability was also very high with an intraclass correlation coefficient of 0.99 (P < 0.001). The correlation of the CSPC to the VAS was 0.94 (P < 0.001) and the CSPC to the GCS was -0.82 (P < 0.001). The CSPC can be a very useful tool for assessing consciousness in palliative care patients. It is very ease to use, not time consuming and can be used with minimal training. Communication between professionals can be improved in the clinical setting and in the research environment.

PMID: 18715971 [PubMed - in process]

Palliative care education in Swiss undergraduate medical curricula: a case of too little, too early.

Palliat Med. 2008 Sep;22(6):730-5

Authors: Pereira J, Pautex S, Cantin B, Gudat H, Zaugg K, Eychmuller S, Zulian G

Palliative medicine education is an important strategy in ensuring that the needs of terminally ill patients are met. A review was conducted in 2007 of the undergraduate curricula of all five of Switzerland's medical schools to identify their palliative care-related content and characteristics. The average number of mandatory hours of palliative care education is 10.2 h (median 8 h; range 0-27 h), significantly short of the 40 h recommended by the European Palliative Care Association's Education Expert Group. The median time allocated to designated palliative care blocks is 3 h (range 0-8 h). Most of the education occurs before the clinical years, and there are no mandatory clinical rotations. Three schools offer optional clinical rotations but these are poorly attended (<10% of students). Although a number of domains are covered, ethics-related content predominates; 21 of a total of 51 obligatory hours (41%). Communication related to palliative care is largely limited to 'breaking bad news'. In two of the schools, the teaching is done primarily by palliative care physicians and nurses (70% or more of the teaching). In the others, it is done mostly by educators in other clinical specialties and ethics (approximately 90% of the teaching). These findings show significant deficiencies.

PMID: 18715972 [PubMed - in process]

Implementation and impact of the Gold Standards Framework in community palliative care: a qualitative study of three primary care trusts.

Palliat Med. 2008 Sep;22(6):736-743

Authors: Walshe C, Caress A, Chew-Graham C, Todd C

The Gold Standards Framework (GSF) has been widely adopted within UK general practices, yet there is little understanding of its impact on the provision of community palliative care services. This study presents data on the anticipation and adoption of the GSF within three Primary Care Trusts in North West England. Forty-seven interviews were conducted with generalist and specialist palliative and primary care professionals. Important aspects of the GSF identified were the patient register, communication and out-of-hours protocols. Positive benefits to professionals included improved communication between professionals and appropriate anticipatory prescribing. Negative aspects included increased nursing workload and the possibility of fewer or later visits for patients. Many respondents believed that the GSF needed local champions to be sustainable. Slow or incomplete adoption was reported. The GSF was recognised as important because it facilitated changes to previously difficult aspects of work between professionals, but few respondents reported direct benefits to patient care.

PMID: 18715973 [PubMed - as supplied by publisher]

Making the most of routine data in palliative care research - a case study analysis of linked hospital and mortality data on cancer and heart failure patients in Scotland and Oxford.

Palliat Med. 2008 Sep;22(6):744-9

Authors: Hanratty B, Goldacre M, Griffith M, Whitehead M, Capewell S

The research base of palliative care is growing rapidly, but despite methodological advances, some of the practical challenges of working with people at the end of life will persist. This means that analysis of routine data is arguably more important in studying palliative care than it is in other aspects of health services research. End-of-life researchers have been using the high-quality linked data from cancer registries for many years. This paper explores the value of a less well-known resource for palliative care research: linked mortality and hospital activity data. Two case studies are presented using information from Scotland (population 5.1 million) and the former Oxford region of England (population 2.5 million). The advantages and limitations of linked hospital and mortality data for research and service planning in palliative care are drawn out through analyses investigating hospital bed utilisation by people with cancer and heart failure and the influence of social deprivation on the use of hospital services in the last year of life. The use of such data deserves a higher profile.

PMID: 18715974 [PubMed - in process]

Clinical and financial analysis of an acute palliative care unit in an oncological department.

Palliat Med. 2008 Sep;22(6):760-767

Authors: Mercadante S, Intravaia G, Villari P, Ferrera P, David F, Casuccio A, Mangione S

The aim of this article is to describe the clinical activity and medical intervention of an acute model of palliative care unit (APC), as well as the reimbursement procedures and economic viability. A sample of 504 patients admitted at an APC in 1 year was surveyed. Indications for admission, pain and symptom intensity, analgesic treatments, procedures, instrumental examinations and modalities of discharge were recorded. For each patient, tariff for reimbursement was calculated according to the existent disease related grouping (DRG) system. The mean age was 62 years, and 246 patients were males. The mean hospital stay was 5.4 days. Pain control was the most frequent indication for admission. All patients had laboratory tests and several instrumental examinations. Almost all patients were prescribed one or more opioids at significant doses, and different routes of administration, as well as medication as needed. 59 patients received blood cell transfusions and 34 interventional procedures. Only 40 patients died in the unit, 11 of them being sedated at the end of life. Treatment efficacy was considered optimal and mild in 264 and 226 patients respectively. A mean of 3019 euros for admission was reimbursed by the Health Care System. APCs are of paramount importance within an oncological department, as they provide effective and intensive treatments during the entire course of disease, providing a simultaneous and integrated approach. Our findings also suggest both a cost and quality incentive for oncological departments to develop APC.

PMID: 18715976 [PubMed - as supplied by publisher]

How does the environment impact on the quality of life of advanced cancer patients? A qualitative study with implications for ward design.

Palliat Med. 2008 Sep;22(6):768-74

Authors: Rowlands J, Noble S

It is well recognized that the ward environment has an effect on patients' quality of life and may, therefore, impact on the quality of end of life care. The body of evidence that informs ward design policy recommends single-bedded rooms on grounds of reduced infection risk, noise and versatility. Considering the majority of anticipated patient deaths occurring in hospitals, the quality of life aspects of ward design should also be considered. The aim of this study is to explore the views of patients with advanced cancer on the effect the ward environment has on their overall well-being. Semi-structured interviews exploring the experiences of 12 inpatients at a regional cancer centre were recorded and transcribed verbatim. Transcripts were analysed for emerging themes until theoretical saturation. Four major themes emerged: staff behaviours, the immediate environment, single vs. multi-bedded rooms and contact with the outside environment. The attitude, competence and helpfulness of the staff creates the atmosphere of the ward regardless of layout, furnishings, equipment and décor. The majority of the patients in this study expressed a strong preference for a multi-bedded room when they were well enough to interact and a single cubicle when they were very ill or dying, which opposes the current advice for building new hospitals with all single rooms. Although the current policy recommends the use of single-bedded rooms, this study suggests the need for a mix of multi-bedded wards and single rooms with respect to the impact of the environment on patient quality of life.

PMID: 18715977 [PubMed - in process]

Outpatient management of malignant pleural effusion with chronic pleural catheter.

Palliat Med. 2008 Sep;22(6):775-6

Authors: Díez-Porres L, Alonso-Babarro A, Iglesias-Docampo A, Díaz-Agero P

PMID: 18715978 [PubMed - in process]

The role of epidural phenol in cancer patients at the end of life.

Palliat Med. 2008 Sep;22(6):777-8

Authors: Finnegan C, Saravanakumar K, Sharma M, Nash T, Corcoran G, Hugel H

PMID: 18715979 [PubMed - in process]