bluuebunny/crossref_metadata_2025 huggingface dataset:
Mainstreaming palliative care for cancer patients in the acute hospital setting
Authors: Llamas K J , Pickhaver A M , Piller N B
Published: May 2003

Palliative care is now emerging as an integrated part of mainstream health care delivery. The importance of patient choice regarding place of dying means that a substantial proportion of palliative care provision occurs in community settings. In part, this is due to the inappropriateness of the acute hospital setting for the care of dying patients. However, most patients with cancer and other terminal illnesses are diagnosed and treated in acute hospitals. Acute hospitals are also the most common setting where people actually die. Therefore, there remains a need for skilled and compassionate provision for the care of dying patients in the acute hospital setting. This paper presents a case for the provision of palliative care services in teaching hospitals. It further argues that a high level of integration between cancer treatment services and palliative care services is needed to optimize the care of cancer patients.
Prevalence and characteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice
Authors: Zeppetella Giovambattista , O'Doherty Catherine A , Collins Silke
Published: May 2003

A prospective survey was undertaken to determine the prevalence and characteristics of breakthrough pain in patients with non-malignant terminal disease admitted to a hospice. Of the 78 admissions surveyed, 10 patients were confused or too unwell to take part and 25 were pain-free. The remaining 43 reported 86 pains (range 1–6 per patient); of these patients, 27 (63%) had breakthrough pain and identified 52 pains (range 1–5 per patient). Breakthrough pain was classified as somatic (46%) visceral (14%), neuropathic (25%) or mixed aetiology (15%); 60% of pains were severe or excruciating. The mean number of daily breakthrough pain episodes was five (range 1–13), 54% of which occurred suddenly. Most pains (56%) were unpredictable; 75% lasted less than 30 min. These findings suggest that breakthrough pain is common in patients with non-malignant terminal disease; it is frequent, short lasting and often unpredictable, thus making treatment difficult.
Receiving a diagnosis of lung cancer: patients' interpretations, perceptions and perspectives
Authors: Yardley S J , Davis C L , Sheldon F
Published: May 2003

Lung cancer has a higher incidence than any other type of cancer and more than 80% of sufferers die within a year of diagnosis. An important aspect of caring for cancer patients is the breaking of bad news, something that most doctors admit to having difficulty with. Only a few publications on this issue adopt the patients' perspective. This study aimed to document patients' views on delivery of lung cancer diagnoses, their attitudes to methods used and ideas for improvement.

Patients were selected from medical, surgical and general practitioner clinics to provide insight into patients' perceptions of care in different environments. Those who gave informed consent completed a taped semi-structured interview. Transcripts were analysed qualitatively using a phenomenological approach. Recruitment was stopped when saturation was reached: no new themes were being identified. A summary of results was sent to patients, whenever possible, for their comment. An independent researcher coded four transcripts to establish the degree of inter-rater reliability.

Thirteen patients were recruited. There were five key areas: communication (including the use of words such as ‘tumour' and ‘growth'), family/community issues, reaction to diagnosis, views on treatment and prognosis (all of which were very variable), and suggested improvements (e.g. a clearer explanation of the experience of bronchoscopy in the patient information leaflet, PIL). Inter-rater reliability was good. The PIL is being revised.

Factors including family situation and personal experience of illness vary greatly and yet they influence patients' reactions to receiving a diagnosis of lung cancer, their interpretation of this and their attitudes to the illness and treatment. These findings underline the need to continue to develop lung cancer services that can provide quality care tailored to each patient.
Cross-cultural validation of the McGill Quality of Life questionnaire in Hong Kong Chinese
Authors: Lo Raymond S K , Woo Jean , Zhoc Karen C H , Li Charlotte Y P , Yeo Winnie , Johnson Philip , Mak Yvonne
Published: May 2003

The main focus of palliative care services is to improve patients' quality of life (QOL). The potential value of assessment of QOL in palliative care is being increasingly recognized. The McGill Quality of Life questionnaire (MQOL) is designed specifically for palliative care patients, but its cross-cultural validity needs to be determined before it can be applied in populations of different cultures and ethnic groups. The cross-cultural validity of MQOL was investigated using a translated and modified version in Chinese–the MQOL-HK–in 462 palliative care patients in Hong Kong. Results show that the MQOL-HK is acceptable, valid and reliable. There is good acceptability, construct validity, convergent and divergent validity, test–retest and inter-rater reliability. Our study confirms that QOL does have cross-culturally robust constructs. Principal components analysis shows that the domains of physical, psychological, existential and support are all relevant and applicable in Chinese culture. Multiple regression analysis reveals that existential domain is the most important domain in predicting overall QOL. ‘Face', eating and sex are additional facets of QOL that also need to be considered. The worst physical symptom on admission is the item of QOL with the lowest score, which need more care and attention by palliative care workers. A cross-culturally validated QOL instrument cannot just help ensure an accurate evaluation of profile, determinants, and changes of QOL, but is also a valuable asset for future comparison and evaluation of palliative care services and interventions across the world.
Palliative care: a suitable setting for undergraduate interprofessional education
Authors: Wee B , Hillier R , Coles C , Mountford B , Sheldon F , Turner P
Published: May 2003

Effective delivery of high-quality palliative care requires effective inter-professional teamworking by skilled health and social care professionals. Palliative care is therefore highly suitable for sowing the seeds of interprofessional teamworking in early professional education. This paper describes experiences of running undergraduate interprofessional workshops in palliative care for medical, nursing, social work, physiotherapy and occupational therapy students. These workshops are unusual in three respects: first, the involvement of family carers mean that these learning experiences are rooted in clinical reality; secondly, there is no attempt to ‘tidy up’ the story for the students; thirdly, unlike many undergraduate interprofessional programmes, these workshops have been sustained over several years. Evaluation of these workshops demonstrate that students value and enjoy the opportunity to work together; they find the experience moving, informative and interesting. Feedback from carers showed that they appreciated the opportunity to present their real-life experiences to students. Our evidence suggests that palliative care is a suitable subject for undergraduate interprofessional education.
Inpatient palliative medicine is evidence based
Authors: Good P , Stafford B
Published: May 2003

Specialist palliative care services have previously been studied to see whether their intervention is of benefit. However, there is a lack of data on whether interventions in individual palliative care units are evidence based. This study looked at 32 problems and 114 interventions over 1 month in January 2000 in an inpatient palliative care unit. These interventions were then researched to see if there had been trials showing their benefit. The results were then classified: 81% were evidence based (randomized controlled trials 48%, evidence from other trials 27%, convincing non-experimental evidence 6%). This compares favourably with studies performed in other areas of medicine.
Decision making in terminal care: a survey of Finnish doctors' treatment decisions in end-of-life scenarios involving a terminal cancer and a terminal dementia patient
Authors: Hinkka H , Kosunen E , Lammi U-K , Metsänoja R , Puustelli A , Kellokumpu-Lehtinen P
Published: May 2003

Goals: The physicians' decision-making process in terminal care is complex: medical, ethical, legal and psychological aspects are all involved, particularly in critical situations. Here, a study was made of the association of personal background factors with end-of-life decisions. Methods: A questionnaire was sent to 300 surgeons, 300 internists, 500 health centre practitioners (GPs) and all 82 Finnish oncologists. The response rate was 62%. Two scenarios were presented: one involving a terminal cancer patient, the other a dementia patient. Sociodemographic factors, general life values and attitudes related to end-of-life care were asked. Main Results: In the cancer case (Scenario 1) 17%, and in the dementia case (Scenario 2) 43% of all the respondents chose active treatment. In a logistic regression analysis of treatment decisions in Scenario 1, physician's age, specialty, marital status and attitudes to assisted suicide and withdrawal of life-sustaining treatment (LST) entered the model. In Scenario 2, the variables were physician's age, physician's own experience of severe disease in the family, attitude to withdrawal of LST and opinion of advanced directives. Conclusions: Doctors' end-of-life decisions vary widely according to personal background factors. The findings underline the importance of advance communication, making these decisions in accordance with the patient's wishes.
Current status of hospice cancer deaths both in-unit and at home (1995– 2000), and prospects of home care services in Japan
Authors: Ida E , Miyachi M , Uemura M , Osakama M , Tajitsu T
Published: May 2003

In Japan, the first government-approved hospice (GAH) and palliative care unit was established and commenced operations in 1990, and hospice medical care was made eligible for health insurance coverage. By 31 December 2000, the number of GAH institutions had increased to 86 (1590 beds). The ratio of hospices to population in Japan is currently approximately 1:1.5 million, with an average of one hospice bed for approximately every 80 000 people. This study of GAH institutions reports a survey conducted to determine the number of deaths (hospice unit and home) of GAH cancer patients, and to determine the servicing status of hospice home care for the period 1995 through 2000. The place of death of the patients cared for by GAHs in 2000 were: hospice units 97.7% and home 2.3%. GAH patient deaths (both inpatient and at home) in 2000 was 2.6% of the total number of cancer patients’ deaths, an increase of 3.8-fold since 1995. Of the total number of GAH institutions, 62% are engaged in home care services and 91% offer hospice care by hospice-assigned doctors. In addition, 72% offer team care with nurses based at Home Care Agencies. In order for the hospice (including home care service) to become established in a way most appropriate to each region of Japan, GAH institutions must assume significant promotional roles in their respective regions. One of the goals and assignments of establishing medical service with hospice home care in Japan is to develop the systematic care programs of GAH institutions, which include home care service in addition to the already established hospice unit and outpatient services.
General practitioners' and district nurses' views of hospital at home for palliative care
Authors: Todd C J , Grande G E , Barclay S IG , Farquhar M C
Published: May 2003

Cambridge Hospital at Home (CH@H) provides 24-h nursing in a patient's own home to patients requiring terminal and palliative respite care. To investigate views of the service, we surveyed all GPs and district nurses (DNs) in the catchment area of the scheme. Responses were received from 85% of DNs and 65% of GPs.

The majority of DNs (93%) and GPs (57%) had patients referred to CH@H, whereas 90% of DNs and 42% GPs had patients admitted. The most commonly reported reason for non-referral was lack of availability of places (GPs 62%; DNs 63%). Ninety per cent DNs and 84% GPs rated continuation of the scheme as important. The most important reported benefits were 24-h care (GPs 84%; DNs 82%) and help in keeping patients at home (GPs 69%; DNs 83%). Seventy-four DNs also considered help in arranging discharge to be important. Almost half GPs and DNs considered CH@H worse than other NHS services in terms of availability and limits on the duration of care. Whilst 65% of DNs thought CH@H had reduced workload, 77% GPs reported it had made no difference or had increased it. Most indicated that CH@H made a difference in allowing patients to die at home (GPs 60%; DNs 68%).

The CH@H scheme is viewed as beneficial for patients requiring palliative care at home, although GPs and DNs expressed realistic reservations about specific aspects of the scheme. With the emergence of Primary Care Trusts, NHS commissioning of hospice at home services will more firmly rest with primary care practitioners, who on balance clearly prize them.
Family satisfaction with inpatient palliative care in Japan
Authors: Morita T , Chihara S , Kashiwagi T
Published: May 2003

Whereas satisfaction is one of the most important outcomes in palliative care settings, there have been no systematic studies investigating the effects of family and organizationrelated variables on family satisfaction with care. To clarify factors contributing to family satisfaction with inpatient palliative care services, a cross-sectional mailed survey was performed.

A 60-item questionnaire was mailed to 1026 bereaved subjects who had lost family members at one of 37 palliative care units in Japan to evaluate their sociodemographic characteristics and satisfaction levels with care. An institution survey was performed to collect organization-related variables. Caregiver satisfaction was rated on the Satisfaction scale for Family members receiving Inpatient Palliative Care (Sat-Fam-IPC). A total of 640 responses were analysed (response rate=62%).

The responses to overall satisfaction were ‘satisfied’ in 41% and ‘very satisfied’ in 47%. The mean total score of the Sat-Fam-IPC was 82.4±13.2 on the 0— 100 scale. The mean subscale scores were: 85.8±14.5 (Nursing Care), 81.5±18.4 (Symptom Palliation), 85.0±13.8 (Facility), 83.3±16.6 (Information), 83.1±17.3 (Availability), 78.3±18.9 (Family Care), and 79.8±17.3 (Cost).

Significant determinants of family satisfaction identified were: nursing system, the number of nurses at night and presence of attending medical social workers (Nursing Care), patient age and the number of physicians (Symptom Palliation), floor space per bed (Facility), duration of admission and presence of attending medical social workers (Availability), patient age, family age, gender and occupational status (Family Care), patient age and the extra charge for a private room (Cost).

In conclusion, informal caregivers are generally satisfied with inpatient palliative care services provided by members of the Japanese Association of Hospice and Palliative Care Units. The levels of satisfaction are influenced by various family and organization-related variables.
How and why do GPs use specialist palliative care services?
Authors: Shipman Catherine , Addington-Hall Julia , Barclay Stephen , Briggs Jill , Cox Ivan , Daniels Lilian , Millar David
Published: May 2003

This study presents findings on the interaction of generalists and specialists within palliative care. General practitioners (GPs) are central to community palliative care as most of the last year of a patient' life is spent at home under the care of the primary health care team. GPs see few palliative care patients each year, however, and access to specialist palliative care services for support, advice and referral can be important particularly to support patients who wish to die at home. The aim of this study was to explore GP use of and attitudes towards specialist palliative care services through semi-structured interviews in inner city, urban and rural areas. It was part of a longitudinal evaluation of an educational intervention, and the quantitative components are reported elsewhere. Sixty-three GPs were interviewed, having been sampled randomly from inner city, urban and rural health authority district lists. While most interviewees reported using specialist palliative care services as a resource, other models of use included working together as an extended team, seldom using such services and handing over care or responsibility entirely. Availability of services clearly shaped use, but previous experience and expectations of easy access were also important. Patterns of use were not necessarily fixed, but dependent also on the differing needs of and wishes of patients and carers. Specialist palliative care services need to be aware of such variations in ways of working and to consider the implications for the capacity and flexibility of both primary care and specialist service provision.
The homeopathic approach to symptom control in the cancer patient: a prospective observational study
Authors: Thompson E A , Reilly D
Published: May 2003

The aims of this study were to describe a population of patients with cancer referred for complementary therapies to an NHS homeopathic hospital, and to explore the homeopathic approach to symptom control and its impact on mood disturbance and quality of life. One hundred consecutive patients attending a designated research cancer clinic were seen for a consultation, lasting up to 60 min, and prescription of a homeopathic remedy. A maximum of three symptoms were identified and rated by the patient as a problem, using a numerical selfrating scale. The effect these symptoms have on daily life and overall sense of well being were recorded using similar scales. Patients completed the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment in Cancer - Quality of Life Questionnaire - Core 30 (EORTC QLQ-30) at the initial consultation and at four to six consultations later. After this time, the patients completed a final assessment questionnaire asking about satisfaction with the homeopathic approach, how helpful they had found the approach for the targeted symptoms and what factors they felt may have contributed to the changes perceived. One hundred patients were entered into the study. Thirty-nine patients had metastatic disease. Nine patients were refusing conventional cancer treatments. The most common symptoms were pain, fatigue and hot flushes. Symptom scores for fatigue and hot flushes improved significantly over the study period but not for pain scores. Side effects included a transient worsening of symptoms in a few cases, which settled on stopping the remedy. Fiftytwo patients completed the study, and in those patients satisfaction was high, and 75% ( n=38) rated the approach as helpful or very helpful for their symptoms. Results suggest that further research is warranted to explore the management of hot flushes in women with breast cancer and fatigue in the cancer diagnosis.
Psychiatric disorder in a palliative care unit
Authors: Durkin Ita , Kearney M , O'Siorain L
Published: May 2003

Introduction: Studies have shown varying prevalence rates of psychiatric disorders in patients with terminal illness. On average it is expected that between 33 and 50% of this population will require psychological support. Despite this, up to 50% of psychiatric disorders remain unrecognized by medical and nursing personnel. The objectives of this study were to assess clinically the prevalence of psychiatric disorder occurring in the study population and to ascertain whether this disorder had been detected and treated prior to admission. Method: Following assessment of the patient, the presence or absence of a psychiatric diagnosis was determined according to the criteria laid down by the ICD-10 Diagnostic Criteria for Research. Results: One hundred and thirty-nine (62%) patients met ICD-10 diagnostic criteria for psychiatric disorder. Thirty-three (24%) patients had dual diagnoses. The commonest diagnoses were organic disorders followed by neurotic and stress-related disorders and depression (27%, 16% and 16%, respectively). One hundred and twenty-six (91%) patients with a psychiatric disorder had been symptomatic on admission. Of these, 35% were receiving incorrect or inadequate treatment. Conclusion:Almost two-thirds of the palliative care population studied had comorbid psychiatric illness. One-third of these disorders had not been identified or treated appropriately prior to admission. Future research needs to identify effective methods of detecting and diagnosing these disorders to enable early and efficient treatment programmes be initiated.
The development of palliative care in national government policy in England, 1986–2000
Authors: Mathew Alison , Cowley Sarah , Bliss Julie , Thistlewood Gillian
Published: May 2003

Palliative care is an established and expanding speciality, important in many areas of service delivery within health and social services and the voluntary sector. Traditionally, palliative care is viewed as most closely linked to cancer services. National government policy has an inevitable impact on the organization and provision of such services. As part of a wider project, an investigation of the content and development of English government policy relating to palliative care was carried out. The development of policy follows a cycle that has no closure; it takes place within changing contexts, between multiple organizations and across sectors. Data collection involved the collation and close examination of policy documents and other documents that demonstrably influenced policy. This was in order to identify a national view of policy intentions for palliative care. In total, 53 policy documents were examined. The analysis revealed a number of pertinent issues relating to shifts in funding policies and an evolving definition of palliative care. There is an increasing recognition in the policy documents of the need for palliative care to extend beyond the traditional focus on cancer services and terminal illness. In tandem, is an increasing recognition of the need for partnership between sectors, reflected in more recent health and social services legislation.
An ad libitum schedule for conversion of morphine to methadone in advanced cancer patients: an open uncontrolled prospective study in a Chinese population
Authors: Tse Doris M W , Sham Michael M K , Ng Daniel K H , Ma H M
Published: May 2003

Methadone has been used as an alternative strong opioid to morphine in the management of cancer pain. The conversion of morphine to methadone is not straightforward because of the high individual variability and unpredictability in the pharmacokinetics of methadone. An ad libitum schedule for conversion of morphine to methadone was used in 37 cancer patients who had intolerable morphine-related side effects or had pain not satisfactorily controlled by morphine. Oral morphine was discontinued on the day of conversion. Methadone was given at a dose calculated as one-twelfth of the total daily dose of morphine, up to a maximum of 30 mg/dose. Methadone was administered at patient-controlled intervals not more frequent than three hours, the need of which was indicated by the presence of pain of moderate intensity or above as rated by a verbal rating scale. When the demand for methadone was stabilized, the total daily dose was given regularly in divided doses. Pain control on day 7 was taken as the primary endpoint. Twenty-seven patients completed the study. Twenty-four patients (88.9%) were in good pain control on day 7, and all reached good pain control by day 11. The median time required to achieve good pain control was three days (range 1 / 11 days). A majority (88.6%) of morphine-related adverse effects improved or resolved after conversion to methadone. This ad libitum schedule is effective in conversion of morphine to methadone in these patients.
An exploration of dignity in palliative care
Authors: Enes Sylvia Patricia Duarte
Published: May 2003

This paper presents a qualitative study exploring the meaning of ‘dignity’ to patients, relatives and professionals. It examines the impact of advanced illness and treatment and the issues pertinent to caring for dignity. Depth interviews were conducted with eight patients, six relatives and seven members of the multiprofessional team. A phenomenological approach to data analysis was adopted. Dignity was found to be a complex phenomenon. It is composed of the dimensions ‘being human’, ‘having control’, ‘relationship and belonging’ and ‘maintaining the individual self’. These dimensions seemed to be held in equilibrium by each individual. The importance of each may alter in response to threats to dignity such as advancing illness and how one is treated within it, in an attempt to cope and adapt. Caring for dignity is challenging because it involves balancing the multiple needs of both users and providers of palliative care and the different perceptions and dimensions of dignity itself.
The acceptability of different routes of administration of analgesia for breakthrough pain
Authors: Walker G , Wilcock A , Manderson C , Weller R , Crosby V
Published: May 2003

Breakthrough Pain In Patients with cancer is common, often unpredictable and can rapidly become severe. Its treatment with orally administered opioids may not be optimal due to the slow onset of pain relief. The parenteral route provides more rapid onset of pain relief but is not always an available, convenient or preferred option. Newer routes of analgesic administration have been or are being developed, such as transmucosal, nasal and inhaled, that aim to combine rapid onset of pain relief with convenience.1 Little is known regarding how acceptable patients view these different routes for the administration of analgesia for breakthrough pain. To begin to explore this we undertook this survey.
The impact of cancer on sexual function: a controlled study
Authors: Ananth Hema , Jones Louise , King Michael , Tookman Adrian
Published: May 2003

Background: Little is known about sexual problems in patients with cancer. Aims: To estimate 1) the prevalence and characteristics of sexual dysfunction in patients undergoing treatment for cancer, 2) how sexual dysfunction varies with stage of illness. Method:Cross-sectional study of outpatients with cancer attending palliative care and oncology services and matched patients without cancer attending general practice. Patients completed a questionnaire on sexual function designed in a feasibility study, the Derogatis subscale on sexual satisfaction, the GHQ12 and the EuroQol. Results: Patients with all types of cancer are willing to talk about their sex lives and the impact of the disease on their sexual function. This impact was significant when compared to the comparison group of general practice attendees of the same age. Palliative care patients were affected more than other cancer patients. Conclusion: This work may lead to greater awareness among healthcare professionals that patients with all types of cancer may experience sexual difficulties. Addressing potential sexual problems during the course of disease may give patients confidence to discuss such issues as they occur, thus avoiding embarrassment or aggravation of the problems later in their illness.
The attitude of health care professionals toward the availability of hospice services for cancer patients and their carers in Saudi Arabia
Authors: Almuzaini A S , Salek M S , Nicholls P J , Alomar B A
Published: May 2003

The main objectives of this study were to assess cancer care and the need for establishing hospice/palliative care for cancer patients and their carers in Saudi Arabia. Six-hundred-and-ninety-five participants (136 cancer patients, 161 informal carers, and 398 health care professionals) were recruited from oncology centres in four major regions of Saudi Arabia. Each group was asked to complete a questionnaire specifically designed to meet the aims of the study. The data obtained from the three different questionnaires indicated that the level of cancer care in the Ministry of Health hospitals was poor compared to other hospitals such as the King Faisal Specialist Hospital and Research Centre, military hospitals or university hospitals in the kingdom, perhaps due to the absence of home care services or periodic follow-up by their regional hospitals. It was also reported that the shortage of drugs used in cancer management, the severe restriction of prescribing narcotic analgesics and lack of cancer care knowledge were the major impediments to providing good cancer care. Thus, the strong inter-relationship among Saudi families, the present poor status of cancer care, cancer patients' and their carers' acceptability of hospice services and of the willingness of health care professionals to receive training in palliative care, illustrate the need for initiating the provision of palliative care services in the Saudi health system.
Health professionals' responses to multiple sclerosis and motor neurone disease
Authors: Carter Helen , McKenna Christine , MacLeod Roderick , Green Robyn
Published: May 2003

This study compares the responses of health professionals to multiple sclerosis (MS) and motor neurone disease (MND) in order to determine similarities and variations in responses to the two disorders and the issues critical to caring for patients with these conditions. Health professionals were more negative about MND compared with MS in terms of the amount they felt able to offer patients, their confidence in managing patients and their ability to convey hope. For a number of issues concerning the management of patients, the level of difficulty experienced by health professionals was similar for both MS and MND. These were resource issues, the health professionals' ability to remain positive in the face of progressive disability, interdisciplinary team problems and difficulties regarding patient care. The main concern of health professionals, for both conditions, was the effect of progressive disability on the patient. For MND, management issues which health professionals found comparatively more difficult than for MS were patients' short prognosis and impending death, communication problems and progressive disability. Issues which were comparatively more difficult for MS than MND were changes in patients' affect, cognition and personality, problems with planning care because of the disorder's unpredictable course, problems with diagnosis such as making and disclosing the diagnosis, and the tendency for patients to be difficult or demanding. Some notable differences in responses between health professionals in different health care settings were found. The findings have implications for changing health professionals' conceptualization of ‘hope’, developing ways of improving communication between health professionals in different health care settings so as to enable them to learn from each other's expertise and experiences and redressing gaps in service provision, especially for young people with MS.
A comparison of artificial saliva and pilocarpine in the management of xerostomia in patients with advanced cancer
Authors: Davies Andrew N , Daniels Charles , Pugh Rosamund , Sharma Kiran
Published: May 2003

This was a crossover study comparing a mucin-based artificial saliva (Saliva Orthana™) and pilocarpine hydrochloride (Salagen™) in the management of xerostomia in patients with advanced cancer. The pilocarpine was found to be more effective than the artificial saliva in terms of mean change in visual analogue scale scores for xerostomia (P = 0.003). Furthermore, more patients reported that it had helped their xerostomia, and more patients wanted to continue with it after the study. However, the pilocarpine was found to be associated with more side-effects than the artificial saliva (P < 0.001). These side-effects were usually reported as being mild. Of the patients who used both treatments, 50% preferred the artificial saliva, and 50% preferred the pilocarpine. The commonest reason for preferring the artificial saliva was the fact that it was a spray, rather than a tablet.
Where do cancer patients die? Ten-year trends in the place of death of cancer patients in England
Authors: Higginson Irene J , Astin Paul , Imperial Susan Dolan
Published: May 2003

Although studies have found that 50–70% of cancer patients would prefer to die at home, there has been a trend towards the hospitalization of the dying in many countries. No study has attempted to analyse the changes in place of death in detail.

The aim was to analyse the 10-year trends in place of death of cancer patients, by region and by diagnosis, within England.

To do this, data on the place of death and patients' characteristics were derived from death registrations for all cancer deaths between the years 1985–94. We examined trends in the place of death for the whole of England, for each region separately and for the main cancer diagnoses.

The results show that there were over 1.3 million death registrations from cancer during the 10 years. The mean age increased over the period from 69.9 years in 1985, to 71.3 years in 1994. The percentage who died in a UK National Health Service (NHS) hospital or nursing home fell gradually from 58% (1985) to 47.3% (1994), while the percentage who died in non-NHS hospitals, nursing homes, hospices and communal establishments increased. The percentage who died at home fell slightly but steadily between 1985 and 1992 from 27% to 25.5% and since then increased slightly to 26.5% in 1994. The percentage of home deaths was lowest in the two Thames regions (less than 25%) and highest in the West Midlands, Anglia and Oxford (over 29%). These differentials were maintained across age groups and diagnoses. Older people and women were less likely to die at home than younger people and men. Significant trends showing an increase in home deaths were found in two regions: North Thames and South Thames. Patients with cancers of the lung, colorectum, respiratory organs, bone or connective tissue and lip, oral cavity and pharynx were more likely to die at home (over 29% in 1994) than patients with cancers of the breast (women, 25% in 1994) or the lymphatic or haematological system (16% in 1994).

It can be concluded that the trend towards a reducing home death rate from cancer in England appears to have halted, although this varies between regions. This has implications for primary care services. Although hospital is still the most common place of death from cancer, the percentage of cancer patients who die in hospital is reducing. The largest rise is in the increasing use of hospices and communal establishments, including residential and nursing homes. Given the ageing population, this trend is likely to continue.
Benzonatate for opioid-resistant cough in advanced cancer
Authors: Doona Marie , Walsh Declan
Published: May 2003

Chronic cough is a distressing symptom experienced by approximately 37% of patients with advanced cancer. Palliation of chronic nonproductive cough should always first address the underlying cause but in some patients chronic, nonproductive cough persists and antitussive agents are required. Opioids are the gold standard cough suppressants, of which codeine is the most widely used; patients with an opioid-resistant cough often prove to be a therapeutic challenge. We report three patients with an opioid-resistant cough who achieved symptomatic relief with the peripherally acting nonopioid drug benzonatate.
The relationship between opioid use and laxative use in terminally ill cancer patients
Authors: Sykes N P
Published: May 2003

The frequency of the use of laxatives, and the relationship between doses of laxatives and of opioid analgesia, were determined by a prospective study of 498 hospice inpatients with advanced cancer. Laxatives were required by 87% of patients taking oral strong opioids, 74% of those on weak opioids and 64% of those not receiving opioid analgesia. The form of the relationship appears to be hyperbolic, as suggested by the presentation of the results arranged by opioid quartile and by the improved correlation obtained by subjecting the opioid data to a logarithmic transformation.

It is concluded that opioids account for about a quarter of the constipation found in terminally ill cancer patients in a hospice. However, the dose of laxative required is likely to be significantly higher if an opioid is being taken than if not. The form of the relationship between laxative and strong opioid doses is what might be expected from the mediation of opioid-induced constipation by opioid receptors.
Autonomy and its implications for palliative care: A northern European perspective
Authors: Farsides C C S
Published: May 2003

This paper explores the implications for palliative care practitioners of the pre-eminence of autonomy as an ethical principle in contemporary health care ethics. It is suggested that some of the consequences of respecting patient autonomy might be unacceptable to carers, particularly when they feel their own autonomy might be compromised or their ethical values threatened.
Nurse–patient communication in palliative care: an evaluation of a communication skills programme
Authors: Wilkinson Susie , Roberts Anita , Aldridge Judith
Published: May 2003

Good communication between nurses and patients is a central aspect of palliative care. However, evaluation of courses designed to improve nurses' communication skills has been inconclusive. Most courses have concentrated on skills training, although communication training programmes which have been integrated into clinical practice over time and have also focused on attitudes and used a range of teaching methods, have been shown to be effective. A study was set up to evaluate whether a communication skills course which would focus on knowledge, attitudes and skills would improve nurses' communication skills. One-hundred-and-ten nurses completed a 26 h training programme over six months and completed precourse and postcourse audiotape recordings of a patient assessment. An overall statistically significant improvement in assessment skills between pretest and post-test mean total scores (P < 0.001) was found, with statistically significant improvements in six of the nine key areas assessed. The nurses reported that although some elements of the programme, such as role play, had been stressful they felt more confident in handling difficult situations. The longer integrated communication skills programme which allows nurses to explore attitudes, raise self-awareness and develop knowledge and skills appears to be effective.
Do hospital palliative care teams improve symptom control? Use of a modified STAS as an evaluation tool
Authors: Edmonds Polly M , Stuttaford Joanna M , Penny Jane , Lynch Anna Marie , Chamberlain Joe
Published: May 2003

The support team assessment schedule (STAS) has previously been validated as an evaluation tool for community palliative care teams and inpatient units. This study reports on use of an expanded STAS (E-STAS) to determine symptom prevalence and outcome for inpatients and outpatients referred to a multiprofessional hospital palliative care team.

E-STAS forms were completed on patients at referral and twice weekly thereafter. Between August 1996 and May 1997, 352 patients had one or more E-STAS forms completed; 122 of this group had three or more assessments. One-hundred-and-eighty-two patients were male and 170 were female, the median age was 68.5 years (range 26–101 years) and all but 27 (8%) had malignant disease. Of the symptoms assessed on referral, the most common were psychological distress 93%, anorexia 73%, pain 59%, mouth discomfort 59%, depression 40%, constipation 36%, breathlessness 32%, nausea 24% and vomiting 13%. In the 122 patients where three or more assessments were completed, statistically significant improvements from first to last assessment were seen in all symptoms except depression.

This study suggests that E-STAS may be a useful tool to evaluate interventions by a hospital palliative care team in patients with advanced disease.
Nonsteroidal anti-inflammatory drugs as adjuvant analgesics in cancer patients
Authors: Jenkins Catherine A , Bruera Eduardo
Published: May 2003

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is examined in the control of cancer pain with a particular focus on their use as adjuvants to opioids in advanced cancer pain. These agents have both a peripheral effect on inflammation and a role in attenuating central pain pathways. The possibility of obtaining the benefits of NSAIDs with fewer side-effects by using COX-2-specific agents is discussed. The gastrointestinal, renal, haemostatic, cognitive and hypersensitivity side-effects of NSAIDs are reviewed and their potential impact assessed. The evidence for the efficacy of NSAIDs as single agents for cancer pain is reviewed together with the nine papers which have reported the effects of NSAIDs as adjuvants to opioids in cancer pain. All of these papers reported positive results of NSAIDs, but, in the absence of any randomized, double-blind controlled trials, where NSAIDs were used as adjuvants on a long-term basis alongside optimal opioid use, definite conclusions cannot be reached. Guidelines for the safe use of NSAIDs are suggested. Finally, suggestions for future research are made.
Lay carers' satisfaction with community palliative care: results of a postal survey
Authors: Lecouturier Jan , Jacoby Ann , Bradshaw Colin , Lovel Tim , Eccles Martin
Published: May 2003

This paper reports the substantive findings of a study that examined the feasibility of using postal questionnaires to assess the satisfaction of lay caregivers with the care received in the community by those dying of cancer. The focus of the analysis was the quality of information provided by health professionals, health services used in the final year of the dying person's life and the lay carer's views about the quality of these services. The study was a retrospective survey of lay carers identified from death certificates over a 9-month period. Of the 355 people contacted, 156 completed the questionnaires, a 44% response rate.

The results of the survey indicate that information provision was deemed unsatisfactory by a large proportion of respondents, and that dissatisfaction with care received from hospital, the district nursing service and the general practitioner was common. Levels of satisfaction with care were clearly related to a range of service factors. Our survey also highlighted clear differences in the perceived quality of specialist and generic services for those dying of cancer. A comparison of the findings from this postal study with those reported in earlier retrospective interview surveys of lay carers suggests that the use of the postal questionnaire is a valid and cost-effective approach for assessing quality of care. The data provide baseline information against which improvements in the quality of care can be measured.
Acute care palliative medicine: psychosocial assessment of patients and primary caregivers
Authors: Powazki Ruth D , Walsh Declan , Horvitz Harry R , Lee  , Burkons Jerome
Published: May 2003

This paper describes the application of an empirically-derived psychosocial assessment for use in advanced cancer. The patient population selected for this study was those patients no longer pursuing aggressive antitumour treatment, and the focus of care was on management of major symptoms and complications, and psychosocial support of the patient and family. The physical, cognitive, social and emotional dimensions were the framework for the assessment of both patient and caregiver functioning. Through this assessment of all patients admitted to our inpatient palliative medicine unit, care needs were identified and psychosocial interventions planned. The results of 150 assessments are reported, as well as observations of the process, implications for psychosocial care and modifications of the assessment based on this experience.
Home palliative care for terminal cancer patients: a survey on the final week of life
Authors: Peruselli C , Di Giulio P , Toscani F , Gallucci M , Brunelli C , Costantini M , Tamburini M , Paci E , Miccinesi G , Addington-Hall J M , Higginson I J
Published: May 2003

As part of a large multicentre study on palliative care units in Italy, carried out between 1 January and 30 June 1995, we describe the place, circumstances and ‘quality of death’ of patients admitted to home palliative care. Data presented refer to 401 patients (67% of the 601 patients randomly selected for evaluation). Of these 401 patients 303 (76%) died at home. According to the Support Team Assessment Schedule (STAS) pain was fairly well controlled during the final week of life, while the control of other symptoms appeared to be less satisfactory. Invasive procedures were undertaken on 56% of patients, while in hospital the percentage increased to 75%. Twenty-five per cent of patients were totally pharmacologically sedated during the final 12 h of life. Neither the number of symptoms nor other factors were apparently associated with the decision to sedate the patient. The wide variations in the frequency of sedation among centres suggest that the choice to sedate the patient may reflect the provider's behaviour or services' policy rather than the patients' preference or needs. The definition of common criteria and guidelines for sedation of patients should be one of the topics for discussion among palliative care teams.
Specialist palliative care and patients with noncancer diagnoses: the experience of a service
Authors: Kite Suzanne , Jones Kate , Tookman Adrian
Published: May 2003

This retrospective review was undertaken to identify the pattern of noncancer referrals to a specialist palliative care service, comprising a teaching hospital support team, home care, outpatients and inpatient hospice, over a 1-year period.

Of 287 hospital ward referrals, 83 patients had a noncancer diagnosis (29%); they were referred predominantly for symptom control (92%), particularly of pain (84%). Of 130 outpatient referrals, 30 had a noncancer diagnosis (23%) and were also referred mainly for the management of pain (85%). Of 196 home care referrals, 18 had a noncancer diagnosis (9%); they tended to be referred for multiprofessional care of endstage disease. Of 421 hospice inpatient admissions, 17 were for patients with a noncancer diagnosis (4%) and were predominantly for respite care. These admissions accounted for 2% of occupied bed days.

It is concluded that specialist palliative care skills are perceived to be transferable to patients with noncancer diagnoses. Resource implications focus on hospital and outpatient services, where shared care with medical teams is usual practice. Defining management goals at the outset is particularly important.