bluuebunny/crossref_metadata_2025 huggingface dataset:
Ask the patient: A semi-structured interview study of quality of life in advanced cancer
Authors: Spiroch Christine R. , Walsh Declan , Mazanec Polly , Nelson Kristine A.
Published: May 2006

The purpose of this exploratory study was to identify important aspects of quality of life for patients with advanced cancer. Thirty patients with advanced cancer were interviewed in this qualitative study using a 23-question, face-to-face format. Questions were asked about affective, global, social, and power domains. Tape-recorded interviews were analyzed using computer data analysis software. Results indicated that patients expressed more positive feelings about their quality of life than expected. Gender differences were noted in responses in the affective, social, and power domains. Family was identified as an important component of quality of life.
Palliative care and hospice: One approach
Authors: Brenner Paul R.
Published: May 2006

The establishment of the first department of pain medicine and palliative care in a medical center in the United States is a significant marker in the development and impact of the palliative care movement. The integration of Jacob Perlow Hospice into this department is a milestone in the continued evolution of the hospice movement in the United States, and suggests that an interrelationship and interdependence between palliative care and hospice is one of the characteristics of change for the future.
Dyspnea assessment and management in hospice patients with pulmonary disorders
Authors: Webb Mary , Moody Linda E. , Mason Linda A.
Published: May 2006

Accurate assessments and appropriate management of dyspnea are essential to provide improved quality of life for hospice patients. This study describes methods of assessing dyspnea and interventions used to manage dyspnea in 72 hospice patients with end-stage lung disease or lung cancer. The mean age of the sample was 72.46 years old and the majority was white (80 percent) and male (62 percent). Paired t-tests were used to compare mean scores on admission and near death for dyspnea severity, Karnofsky functional status, pain, and Mini-Mental Status scores. Results showed significant decline in functional and cognitive status, but no significant changes in dyspnea severity and pain. Dyspnea was often assessed subjectively with observational methods only. Use of inhalants, oxygen, positioning, steroids, and oral opioids were the most frequent therapies for dyspnea. Relaxation, guided imagery, and other complementary therapies were rarely used (five percent or less). Measurement of dyspnea needs to be done frequently by using standardized instruments to assess severity and degree of symptom distress as well as the effects of treatment. Clinical trials are needed to determine which dyspnea interventions are most effective in terminally ill patients. Guidelines such as those developed for pain management are needed for effectively managing dyspnea.
Hydrocodone for cough in advanced cancer
Authors: Homsi Jade , Walsh Declan , Nelson Kristine A. , LeGrand Susan B. , Davis Mellar
Published: May 2006

Cough is a common symptom in advanced cancer. Hydrocodone is the antitussive of choice in our palliative medicine inpatient unit. We reviewed the pharmacy records for the use of hydrocodone for all cancer admissions to our unit from May 1996 to December 1998. Median treatment duration with hydrocodone was three days (range 1-18). Median maximum daily dose was 15 mg (range 5-100), and median total dose during the hospital stay was 32 mg (range 5-455). Lung cancer as a primary cancer site was strongly related to the use of hydrocodone. The highest median duration of treatment (five days) was for esophageal cancer and the highest median maximum daily dose (35 mg) and total dose (75 mg) were for treating kidney cancer. This retrospective review provides information regarding the use of hydrocodone on the palliative medicine unit of the Cleveland Clinic Foundation. Controlled trials are needed to evaluate the efficacy and safety of hydrocodone for cough in advanced cancer.
Use of continuous ambulatory infusions of concentrated subcutaneous (SQ) hydromorphone versus intravenous (IV) morphine: Cost implications for palliative care
Authors: Fudin Jeffrey , Smith Howard S. , Toledo-Binette Charlotte S. , Kenney Ellen , Yu Andrew B.C. , Boutin Ronald
Published: May 2006

Health care practitioners are increasingly under pressure to curtail spending while trying to deliver excellent patient care. These issues are also affecting palliative care, particularly now that palliative care programs are expanding. A comparison of cost-effectiveness and feasibility of using continuous subcutaneous (SQ) ambulatory infusion of hydromorphone versus intravenous (IV) ambulatory morphine is illustrated in this study. With the high doses of morphine required in chronic cancer pain, the use of subcutaneous morphine is not feasible due to the volume of solution required to be delivered. Hydromorphone can be prepared in concentrated solutions enabling it to be delivered by the subcutaneous route. Morphine stability data are available. However, hydromorphone stability has only been verified for seven days; thus, stability data were needed post-seven days. Concentrations of 10 mg/ml, 20 mg/ml, 50 mg/ml, and 100 mg/ml, in 0.9 percent normal saline or dextrose 5 percent water, were analyzed via high-performance liquid chromatography (HPLC) at seven and 28 days. Cost comparisons of supplies and associated costs with subcutaneous versus intravenous solutions were obtained. Hydromorphone was found to be stable for 28 days in both dilutents. Cost analysis of a hydromorphone 28-day supply resulted in substantial savings over the equivalent costs of morphine infusions.
The transitional phase: The closing journey for patients and family caregivers
Authors: Doyle-Brown Marina
Published: May 2006

The ability to identify physical waypoints along the continuum of illness may give end-stage patients and their families opportunities for goal reframing and risk reduction. That period which exists between active participation in the activities of daily living and a bedbound status, herein described as the transitional phase, is characterized by the four precursive, or seminal, behaviors of anorexia, increased sleep, weakness, and confusion, and the two cardinal behaviors of incontinence and falls. It is a time of heightened anxiety for families and risk of injury for patients. The ability to identify these behaviors as part of a definable phase, with a beginning and an end, allows the health care clinician or hospice worker to educate the family, assisting with goal reassignment, risk reduction, and diminishment of anxiety. Family understanding of the finite nature of the transitional phase may also reduce the need for placement outside the home for those wishing their loved one to die at home, and provide the caregiver with meaningful participation in end-of-life problem solving.
Nebulized hydromorphone for dyspnea in hospice care of advanced cancer
Authors: Sarhill Nabeel , Walsh Declan , Khawam Elias , Tropiano Pamela , Stahley Mary Kay
Published: May 2006

This case report describes the use of nebulized hydromorphone for management of dyspnea in advanced cancer in home hospice care. The patient was intolerant of morphine; nebulized hydromorphone was used as an alternative to nebulized morphine for dyspnea and found to be both safe and effective.
Methylphenidate for depression in hospice practice: A case series
Authors: Homsi Jade , Walsh Declan , Nelson Kristine A. , LeGrand Susan , Davis Mellar
Published: May 2006

Psychostimulants such as methylphenidate have been used for depression in cancer patients. We report the successful use of methylphenidate to treat depression in 10 consecutive patients with advanced cancer. A rapid onset of effect was noted. Appetite, concentration, fatigue, and sedation also improved in some persons. No severe side effects were noted.
Attitudes, values, beliefs, and practices surrounding end-of-life care in selected Kansas communities
Authors: Felt Diane Heilman , Early James L. , Welk Thomas A.
Published: May 2006

Objective: This study was designed to better meet end-of-life care needs for patients and their families in rural Kansas communities.

Methods: Initially, statistical information indicated an underutilization of hospice services in rural communities. To evaluate the data, focus groups were conducted in targeted communities in order to determine attitudes, values, beliefs, and practices surrounding end-of-life care. A script was developed using established focus group protocols. Each focus group was recorded and the tapes were transcribed. Transcripts were reviewed and categorized for similarities and emerging key issues.

Results: Five major areas of concern were identified using this methodology. Major concerns were: (1) participants believed that control over decisions about care at the end of life is the patient’s right; (2) while participants saw a need for advance directives, they avoided using them; (3) group participants believed that the patient’s wishes should be given first priority and this was viewed as a patient’s right; (4) there was an expressed lack of trust in the existing health care system and its providers; and (5) participants expressed more fear over the manner of death than death itself. They fear a technological death as opposed to a good death.

Conclusions: The values most important to the group participants included: freedom and independence, trust, honesty, the right to information, and the importance of family. This information will be utilized in the development of programs and interventions to effect changes in end-of-life care, not only in Kansas, but also in areas with a comparable population.
The ballet of baseball: Lessons of the game for hospice
Authors: Norlander Linda , Grimmer Thomas
Published: May 2006

As Yogi Berra once said, “The future ain’t what it used to be.” In the era of rapid change in health care, hospice and palliative care programs will survive only through organizational teamwork. Using the lessons of baseball, we present a stadium-eye perspective on how programs can take the three fundamentals of base-ball—pitching, batting, and fielding—and translate them into the three fundamentals of organizational team-work—clinical, operational, and financial. The best clinicians (pitchers) are of no use if the office operations (batting) keep the patients (fans) out of the stadium and no program can survive without the financial resources (fielding.)
The business of palliative medicine: Management metrics for an acute-care inpatient unit
Authors: Davis Mellar P. , Walsh Declan , Nelson Kristine , Konrad Dale , LeGrand Susan B.
Published: May 2006

For any palliative medicine inpatient unit to be economically viable, certain management metrics need to be followed. Palliative medicine can provide both a compassionate and economical service within the current acute inpatient hospital environment. In this article, we will review the administrative and financial factors we have identified that influence the business of acute palliative medicine.
Dealing with AIDS-related loss and grief in a time of treatment advances
Authors: Demmer Craig
Published: May 2006

Recent advances in the treatment of HIV/AIDS have dramatically changed the lives of many patients and their loved ones as well as those who care for them. However, not all patients respond successfully to the latest treatments. Hospice professionals need to understand the experience of AIDS patients and their loved ones in this period of hope and disappointment, and to find appropriate ways to support and care for them. This article explores the implications of treatment advances for AIDS patients, their loved ones, and professionals in dealing with loss and grief.
Mirtazepine: Heir apparent to amitriptyline?
Authors: Davis Mellar P. , Dickerson E. Duke , Pappagallo Marco , Benedetti Costantino , Grauer Phyllis A. , Lycan Jeff
Published: May 2006

“What’s new in therapeutics?” will examine and evaluate drugs that may have a place in hospice, palliative, and long-term care. Mirtazepine will be examined and evaluated. Mirtazepine is a potential alternative anti-depressant with multiple additional benefits. It is an atypical anti-depressant, which has both noradrenergic and specific serotonergic receptor antagonism (NaSSa), and a unique pharmacological profile. Mirtazepine appears to be a “designer drug” for palliative medicine with a number of benefits, but cost may be a drawback.
Methadone-induced myoclonus in advanced cancer
Authors: Sarhill Nabeel , Davis Mellar P. , Walsh Declan , Nouneh C.
Published: May 2006

Methadone is recommended as being free of some of the neuropsychological side effects noticed with morphine, which are attributed to active metabolites. A patient that received methadone for cancer-associated pain developed myoclonus as a side effect. This has rarely been reported before in the literature. The pathophysiology and management of myoclonus are discussed.
Process evaluation of an educational intervention to improve end-of-life care: The Education for Physicians on End-of-Life Care (EPEC) Program
Authors: VanGeest Jonathan B.
Published: May 2006

Despite the growing importance of end-of-life care and the need to improve it, physicians receive little formal training in palliative care. The Education for Physicians on End-of-life Care (EPEC) project, developed by the American Medical Association and the Robert Wood Johnson Foundation, tested a train-the-trainer educational intervention to address this deficiency. This paper presents data from a process evaluation of the initial rollout of EPEC. By all accounts, EPEC provided a state-of-the-art curriculum covering important and clinically relevant topics to the care of the dying patient. It was less clear, however, if EPEC adequately prepared trainees to teach these new skills to other practicing physicians. Factors that may advance efforts to generalize EPEC to other settings and improve future applications of the program are discussed.
The terminally ill Muslim: Death and dying from the Muslim perspective
Authors: Sarhill Nabeel , LeGrand Susan , Islambouli Ramez , Davis Mellar P. , Walsh Declan
Published: May 2006

Islam holds life as sacred and belonging to God and that all creatures will die one day. Suicide is forbidden. Muslims believe death is only a transition between two different lives. The terminally ill Muslim desires to perform five ritual requirements. Do not resuscitate (DNR) orders are acceptable. A deceased Muslim must always be buried after being ritually washed and wrapped. There are different Muslim schools of thought, but they are united regarding their views on death and dying.
Marijuana in the management of amyotrophic lateral sclerosis
Authors: Carter Gregory T. , Rosen Bill S.
Published: May 2006

Marijuana has been proposed as treatment for a widening spectrum of medical conditions. Marijuana is a substance with many properties that may be applicable to the management of amyotrophic lateral sclerosis (ALS). These include analgesia, muscle relaxation, bronchodilation, saliva reduction, appetite stimulation, and sleep induction. In addition, marijuana has now been shown to have strong antioxidative and neuroprotective effects, which may prolong neuronal cell survival. In areas where it is legal to do so, marijuana should be considered in the pharmacological management of ALS. Further investigation into the usefulness of marijuana in this setting is warranted.
Needs and experiences of non-English-speaking hospice patients and families in an English-speaking country
Authors: McGrath Pam , Vun May , McLeod Lesley
Published: May 2006

There is increasing evidence that, in practice, hospice care is predominantly accessed by white, middle-class patients, who live in stable home environments with available caregivers and other supports. The present challenge for researchers, administrators, and clinicians is to identify populations of terminally ill patients most in need of hospice care and to direct services to these patients. As a contribution to the development of this area, this paper presents the findings from a recent Australian hospice study that examines the needs and experiences of families from non-English-speaking backgrounds. The findings indicate that it is as important to focus on similarities as it is to highlight differences.
Dying in long-term care facilities: Support needs of other residents, relatives, and staff
Authors: Katz Jeanne Samson , Sidell Moyra , Komaromy Carol
Published: May 2006

This paper explores the support needs of residents, relatives, and care staff when someone dies in a facility for older people. The authors draw on the qualitative findings from an English study, which investigated the case for applying the principles and practices of palliative care to people dying in these settings.

Relatives need practical as well as emotional support, which is often not met adequately by nursing home staff. Managers varied in the extent to which they recognized other residents’ emotional needs or supported relatives. Care staff members acknowledged needing practical and emotional support, but management was often unable to deliver it. Lack of training in recognizing and addressing needs in addition to financial and staffing constraints were factors that prevented managers from providing support for staff, residents, and relatives.
Management strategies for palliative care: Promoting quality, growth and opportunity
Authors: Herbst Laurel H. , Cetti Jan
Published: May 2006

Over 20 years ago, hospice in the United States evolved to provide end-of-life care for terminally ill patients. However, three major barriers exist, which limit access to hospice care. The first two, cultural and regulatory barriers, are not under the direct control of hospices, although programs can be adapted to minimize their influence. The third, management focus, is controlled by hospice programs and has the greatest influence on access to care and quality of care. Under the influence of the Medicare Hospice Benefit and the peer pressure of managed care, many hospice programs use reimbursability as at least one criterion for determination of coverage of services. The fear is that limited reimbursement will cause some services and therapies to bring the programs to financial ruin. This case study shows the outcome of changing management focus away from restrictive policies about therapies and patient selection toward management of productivity and working capital.

Some programs have contributed to growth and stability; the revenue thus produced has supported the new innovations. San Diego Hospice is now growing more than 30 percent per year in spite of competition and a fairly flat death rate in the community. This growth is attributed to finding and meeting unmet needs and making all decisions based on the right thing to do. Every staff member understands and supports the mission. The many programs within the agency contribute to fulfillment of the goal to transform end-of-life care. They are presented here as an example of what can be done with mission-based management.
The palliative use of high-dose corticosteroids in three terminally ill patients with pain
Authors: Rousseau Paul
Published: May 2006

Corticosteroids are valuable pharmacological adjuncts utilized in the management of the diverse symptoms observed in terminally ill patients, including bone, neuropathic, and hepatic pain, asthenia and fatigue, and anorexia, and serve as an adjunct for the treatment of nausea and vomiting. If relief of suffering is the goal and mandate of palliative care, high-dose corticosteroids should be utilized in terminally ill patients for quickly reducing pain and improving quality of life for both patients and family members. In patients with a limited life expectancy of days to several weeks, long-term side effects will not occur and therefore should not preclude the continuous use of corticosteroids until the patient’s death. Three case studies are presented.
Thalidomide: Dual benefits in palliative medicine and oncology
Authors: Davis Mellar P. , Dickerson E. Duke
Published: May 2006

Thalidomide is an immunomodulator, anti-angiogenic agent, anti-cytokine, and anti-integrin. Alone or in combination with other drugs, thalidomide has also demonstrated anti-cachexin and anti-neoplastic properties.

Anorexia and cachexia are common symptoms of advanced cancer. Since certain cytokines also promote tumor growth, we may have a class of agents with palliative and anti-tumor benefits in combination with anti-neoplastics and anti-cytokines, such as thalidomide.
Mexicans and care for the terminally ill: Family, hospice, and the church
Authors: Gelfand Donald E. , Balcazar Hector , Parzuchowski Jeanne , Lenox Susana
Published: May 2006

The structural barriers to the use of hospice services by minority groups have been widely discussed. The attitudes of these groups are less clearly delineated. A series of focus groups with Mexicans was held in Michigan and Arizona. The participants were between the ages of 45 and 64 or over, as well as providers of services to Mexicans. Regardless of length of time in the United States, participants were low on acculturation scores. These groups found important attitudes about the roles of the family, hospice services, and spirituality and the church in providing care to terminally ill individuals.
A phase II study of methylphenidate for depression in advanced cancer
Authors: Homsi Jade , Nelson Kristine A. , Sarhill Nabeel , Rybicki Lisa , LeGrand Susan B. , Davis Mellar P. , Walsh Declan
Published: May 2006

This study evaluated the use of methylphenidate for depression in advanced cancer.

Design: Phase II open-label prospective study.

Eligibility criteria: No previous use of methylphenidate or current use of other antidepressants.

Evaluation: Depression and response to treatment were determined by asking the patient: “are you depressed?” Patients were assessed at baseline and at days 3, 5, and 7.

Treatment: Starting dose was 5 mg at 8:00 a.m. and 12:00 noon. The dose was titrated for lack of response on any of the assessment days.

Response criteria: A negative response to the question: “are you depressed?”

Results: Some 41 patients were enrolled and 30 (15 men, 15 women) completed the study. Median age was 68 years (range: 30-90). Methylphenidate was stopped for six patients because of side effects and five were not evaluable; 21 responded to 10 mg/day on day 3; the other nine responded to 20 mg/day on day 5; 29 maintained their positive response through day 7. Anorexia, fatigue, concentration, and sedation also improved in some. All who completed the study had tolerable side effects, none of which caused treatment to stop.

Conclusions: Methylphenidate is effective for depression in advanced cancer. A starting dose of 10 mg in divided doses is effective in most patients. Dose escalation may be needed. Improvement occurs within three days. Close monitoring of side effects is recommended.
Patient and caregiver satisfaction with end-of-life care: Does high satisfaction mean high quality of care?
Authors: Steele Linda L. , Mills Beth , Long Marty R. , Hagopian Gloria A.
Published: May 2006

The purpose of this study was to determine patient and caregiver satisfaction with a hospice program of care. The setting for the study was a home-care hospice in the southeastern United States that provides a full range of services for patients with life-limiting illness and supportive services for family caregivers. Two Likert-type instruments were used to determine satisfaction with staff, communication, education, information provided, symptom management, promptness with service, and overall satisfaction. Some 321 patients and 443 caregivers completed surveys over a two-year period of time. Data indicates the majority of patients and their care-givers were very satisfied with hospice services and the care they received. Providing quality care at the end of life is the goal of hospice. Satisfaction with delivery of care, management of symptoms, and communication with staff are all components of quality care and contribute to quality of life.
Management of symptomatic ascites in recurrent ovarian cancer patients using an intra-abdominal semi-permanent catheter
Authors: Iyengar Tara D. , Herzog Thomas J.
Published: May 2006

Ascites is commonly present in women with advanced-stage ovarian cancer. No standardized protocol exists for the treatment of the patient with recurrent ovarian cancer and rapidly reaccumulating malignant ascites. Palliation of symptoms is most commonly achieved through repeated paracentesis, a procedure that potentially results in injury to intra-abdominal organs, infection, and patient discomfort. Our goal was to improve patient comfort by alleviating symptoms and reducing the need for paracentesis. The Pleurx ® catheter offers a number of potential advantages over traditional treatment modalities. Clearly, larger study numbers are required to quantify the morbidity associated with the Pleurx ® catheter.
Assessment of pain and health-related quality of life in slowly progressive neuromuscular disease
Authors: Abresch Richard T. , Carter Gregory T. , Jensen Mark P. , Kilmer David D.
Published: May 2006

Few studies have examined the effect of pain on the quality of life of individuals with slowly progressive neuromuscular disease (NMD). The purpose of this study was to determine the frequency and extent to which subjects with slowly progressive NMD report pain and the association between pain and health-related quality of life in persons with NMD. The study design was a descriptive, nonexperimental survey. Of a total of 1,432 subjects with slowly progressive NMDs recruited from a university-based NMD clinic and the membership rosters of worldwide NMD support organizations, 859 agreed to participate. The primary measurement tool used was the Medical Outcomes Study SF-36 health survey. Our results indicated that, with the exception of adult spinal muscular atrophy (SMA), the frequency and severity of pain reported in slowly progressive NMDs was significantly greater than levels of pain reported by the general US population and was comparable to pain reported by subjects with osteoarthritis and chronic low back pain. There was a significant correlation between increased pain and lower levels of general health, vitality, social function, and physical role. Pain was moderately associated with increased fatigue, inability to cope adequately with stress, and sleep disturbance. In conclusion, with the exception of adult SMA, the frequency and severity of pain reported in slowly progressive NMDs was significant.
The business of palliative medicine—Part 2: The economics of acute inpatient palliative medicine
Authors: Davis Mellar P. , Walsh Declan , Nelson Kristine A. , Konrad Dale , LeGrand Susan B. , Rybicki Lisa
Published: May 2006

Economic feasibility is a major factor in the viability of established acute inpatient palliative medicine. Several clinical, administrative, and financial parameters determine the financial health of inpatient care. Financial management metrics include case mix index (CMI) (as determined by the Federal Register as an assigned relative weight to the diagnosis-related group (DRG) reflecting resource consumption), direct costs, indirect costs, contribution margin, and in the future of all patient revised-DRG (APR-DRG). Both census and length of stay will have a major impact on these financial metrics. The type of patient referral and clinical decisions will influence direct costs and revenues. In the future, an international CMI or APR-DRG will allow palliative inpatient units to compare disease severity, resource utilization, and outcome measures.
Ergonomic and demographic issues reported by palliative care workers in southern Taiwan
Authors: Smith Derek Richard , Guo Yueliang Leon , Lee Yung-Ling , Chang Suh-Jen
Published: May 2006

Aim: To investigate ergonomic and demographic issues reported by palliative care workers in southern Taiwan.

Method: A structured questionnaire was completed by staff members from 11 nursing homes within southern Taiwan. Questions focused on age, sex, height, weight, shift-work details, duration of current employment, nature of current employment, the presence of injury and pain during the past 12 months, the phase lag before the onset of injury, and sick leave details.

Results: A total of 125 health-care workers were recruited. Most were female (89.3 percent) and employed full-time (64.8 percent) as patient care assistants (55.2 percent). Most workers were regularly involved in patient-handling tasks (61.6 percent). Almost half (36.8 percent) had suffered a musculoskeletal disorder within the previous year. Lower back injury was reported by 12.0 percent of all employees. Changing patients’ clothes and changing their bed linen were associated statistically with musculoskeletal injury (odds ratio (OR) 2.9, 95 percent confidence interval (CI) 1.4-6.3 and OR 2.8, 95 percent CI 1.4-6.1), respectively. Moving the patients was also related to injury during our research (OR 2.5, 95 percent CI 1.2-5.4).

Conclusion: This study has revealed various ergonomic and demographic issues reported by palliative care workers in southern Taiwan for the first time. The prevalence of certain injuries and symptoms are different from other reports.
Perspectives of relatives and health care workers on care of terminally ill patients in the UK
Authors: Ferry Peter , Hancock Richard , Newton Cindy , Taylor John , Horton Kim
Published: May 2006

Two parallel questionnaires were used to explore perceptions of health-care workers (HCWs) and the relatives of terminally ill patients on the quality of care received by the patients. There was general agreement between the two groups of respondents in most of the assessed areas. The relatives, however, were more satisfied with the control of pain and psychological symptoms than the HCWs, and the HCWs perceived the control of diarrhea, skin problems, and swallowing problems more positively than did the relatives. There also was some variation between the two groups in their perception of the care received by the relatives during visits at the hospital, with the relatives’ group being more positive. Although HCWs reported that time to deal with patients and their families was inadequate, the relatives’ group was generally satisfied with the standards in place.
Barriers, challenges, and opportunities related to the provision of hospice care in assisted-living communities
Authors: Dixon Sharon , Fortner Janet , Travis Shirley S.
Published: May 2006

The purpose of this project was to clarify the barriers, challenges, and opportunities associated with providing care to older adults residing in assisted-living communities. Three focus groups (hospice team members, family members of individuals who received hospice care while in assisted living, and administrators of assisted-living communities) were convened to discuss hospice care. Thematic analysis of the transcribed focus group tapes was used by the authors to identify the common and unique barriers, challenges, and opportunities identified by each group.

All three groups were overwhelmingly in support of the right of residents in assisted-living communities to live and die in place, without being transferred to nursing homes or other acute-care facilities, and of the role that hospice plays in enabling residents to achieve that goal. The three groups also agreed that trends in the development of assisted-living communities create difficulties for the industry, confusion for consumers, and the need for increased accountability by providers.

Delivering hospice care to places where consumers want to live and die in place will be a complex task. Among other things, traditional hospice care is not easily transported into the social models of care characterized by assisted-living environments. Changes in hospice organization policies and procedures will be necessary, as will broader, industry-wide reforms in areas such as recruitment, retention of qualified staff, and consistent quality-of-care standards.
A phase II study of low-dose megestrol acetate using twice-daily dosing for anorexia in nonhormonally dependent cancer
Authors: Nelson Kristine A. , Walsh Declan , Hussein Mohamad
Published: May 2006

Anorexia is a common problem in advanced cancer. Low-dose megestrol acetate, a semi-synthetic progesterone, given twice daily, is an effective appetite stimulant in advanced cancer patients. There was an excellent correlation between patient satisfaction and the primary response criteria (appetite improvement). Given cost, side-effect profile, ease of administration, and efficacy, 80 mg twice daily after meals is an appropriate starting dose of megestrol acetate for anorexia in advanced cancer. If this is not effective, considerable dose escalation is possible.
Beyond principles: Virtue ethics in hospice and palliative care
Authors: Giblin Marie J.
Published: May 2006

Living ethically in the face of death is a major challenge for the ill person, the family, and the hospice staff. Beyond the recognized need for ethical decision-making regarding medical principles, there are decisions about character for all involved: “What kind of person will I be?” “What kind of family will we be?” “What kind of caregiver will I be?” “What kind of community will we be?”

This article is a discussion of virtues that are appropriate in hospice staff and volunteers: compassion/empathy, faithfulness, justice/advocacy, and practical wisdom. The author calls for a wider sharing of their knowledge and experience.
Palliative medicine in a United States cancer center: A prospective study
Authors: Cowan John D. , Walsh Declan , Homsi Jade
Published: May 2006

Purpose: (a) To report the medical complexity of cancer and noncancer patients receiving palliative medicine (PM) consultation at a tertiary medical center and (b) to describe the consult recommendations made for this group.

Patients and methods: Prospective data collection was performed on all consultations (cancer, n = 175; non-cancer, n = 35) done by first author (JDC) as a PM fellow at the Cleveland Clinic Foundation between July 1998 and April 1999. A computer database was used to query for demographics, complexity of medical problems, current medications, mortality, symptoms, nursing problems, and consult recommendations.

Results: A median of three (range, 0-12) acute medical problems and three (range, 0-16) chronic medical problems were identified for each patient. Patients were taking a median of six medications (range, 0-20). They had a median of five symptoms (range, 0-13) with pain (73 percent) being most common, followed by weakness (40 percent) and shortness of breath (40 percent). Cancer patients were twice as likely to have more than five symptoms (48 percent versus 23 percent) (chi-square = 0.006). The most common nursing problems were ambulation or fall risk (15 percent) and skin integrity (11 percent). A median of five (range, 1-11) management recommendations were made as part of each consultation. These included medication changes in 81 percent, nonmedication changes in 53 percent, and follow-up services in 100 percent. The median survival from the time of consultation for the known dead was 29 days with 65 percent living more than 14 days.

Conclusion: Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.
Communicating with dementia patients on hospice
Authors: Thompson Patricia M.
Published: May 2006

There are distinct differences in caring for the “typical” hospice patient as opposed to the hospice patient who has Alzheimer’s disease. The entire hospice team, from volunteers to physicians, can benefit from dementia-specific training in this area. This article addresses this topic in terms of what to be aware of in the disease process, understanding and responding to the caregiver’s experience and needs, and, of course, patient care. Particular communication techniques are presented to facilitate interactions with the dementia patient at each of the stages of his or her disease.
Episodic pain in patients with advanced cancer
Authors: Zeppetella Giovambattista , Ribeiro Maria D.C.
Published: May 2006

Episodic pain is a common problem for patients with advanced cancer and is often difficult to manage successfully. In this article, the daily variations in cancer-related episodic pain in a patient with metastatic lung cancer are described. The definition, etiology, prevalence, and pharmacological management of episodic pain are also reviewed.
The efficacy and side effects of continuous infusion intravenous morphine (CIVM) for pain and symptoms due to advanced cancer
Authors: Glare Paul , Walsh Declan , Groh Eileen , Nelson Kristine A.
Published: May 2006

Morphine is the strong opioid of choice in the management of moderate-to-severe chronic cancer pain. The preferred route of administration is oral, in individually titrated doses, regularly scheduled around the clock. We conducted a retrospective study of continuous intravenous morphine (CIVM) in a palliative medicine program in 107 consecutive patients. The results suggest CIVM is an effective, safe, and versatile method of morphine administration when used with a defined protocol. Efficacy was similar to that obtained by others with intravenous morphine sulfate and also for oral morphine. Safety was suggested by the low incidence of dose-limiting side effects, most of which responded to dose reduction. Particularly noteworthy was the flexibility of CIVM with dose reduction in 20 percent.
Gastrointestinal symptoms among inpatients with advanced cancer
Authors: Komurcu Seref , Nelson Kristine A. , Walsh Declan , Ford Rashawn Bradley , Rybicki Lisa A.
Published: May 2006

Nearly one-half of the most frequently reported and most distressing symptoms in patients with advanced cancer are gastrointestinal in nature. This prospective study was designed to assess the frequency of gastrointestinal symptoms among inpatients admitted to a palliative medicine program with advanced cancer.

Twenty-nine men and 21 women, with a median age of 64 years (range, 35-84), were interviewed about 17 gastrointestinal symptoms. Age, gender, diagnosis, and medication use were also recorded.

The most common diagnoses were cancers of the lung (n = 14), breast (n = 6), and prostate (n = 4). Dry mouth (84 percent), weight loss (76 percent), early satiety (71 percent), taste change (60 percent), constipation (58 percent), anorexia (56 percent), bloating (50 percent), nausea (48 percent), abdominal pain (42 percent), and vomiting (34 percent) were the 10 most common gastrointestinal symptoms. Women had more gastrointestinal symptoms than men (median 8 vs. 6, p = 0.018), although this finding was not statistically significant (p = 0.11) after excluding gender-specific cancers. Women had more taste change and diarrhea than men after excluding gender-specific cancers (p = 0.036 and p = 0.046, respectively). Those with primary gastrointestinal cancers (n = 8) had more indigestion and hiccups than those with nongastrointestinal cancers (n = 39). There was no age difference in symptomatology. The drugs prescribed most commonly were opioids (n = 40), laxatives (n = 38), H 2 blockers (n = 29), appetite stimulants (n = 29), and antiemetics (n = 29).

Findings support that gastrointestinal symptoms are very common in hospitalized patients with advanced cancer and that the frequency and type of symptoms differ with gender and gastrointestinal vs. nongastrointestinal primary site.
Communicating with surrogate decision-makers in end-of-life situations: Substitutive descriptive language for the healthcare provider
Authors: Limerick Michael
Published: May 2006

This article discusses the manner and actual wording used by health-care providers in communicating difficult information as it relates to end-of-life discussions. Several examples are given and substitutive language is suggested for more effectively obtaining informed consent from surrogate decision-makers, who are often responsible for determining the course of care for the terminally ill.
Use of aromatherapy with hospice patients to decrease pain, anxiety, and depression and to promote an increased sense of well-being
Authors: Louis Margaret , Kowalski Susan D.
Published: May 2006

This study measured the responses of 17 cancer hospice patients to humidified essential lavender oil aromatherapy. Vital signs as well as levels of pain, anxiety, depression, and sense of well-being were measured (using 11-point verbal analogs). Each subject was measured on three different days before and after a 60-minute session consisting of (1) no treatment (control); (2) water humidification (control); or (3) 3-percent lavender aromatherapy. Results reflected a positive, yet small, change in blood pressure and pulse, pain, anxiety, depression, and sense of well-being after both the humidified water treatment and the lavender treatment. Following the control session (no treatment), there was also slight improvement in vital signs, depression, and sense of well-being, but not in pain or anxiety levels.
District nurses’ perceptions of palliative care in the home
Authors: Berterö Carina
Published: May 2006

Palliative care describes a caring philosophy. Originally, palliative care referred exclusively to the care of dying cancer patients, but over time has expanded to include mitigating care of all dying people whatever the diagnosis. The purpose of this paper is to explore the meaning of palliative care according to the experience of district nurses in Sweden. Six district nurses were interviewed, and the transcripts were analyzed using Giorgi’s phenomenology. The essence of the caring philosophy for the nurses in the study was identified as commitment, underscored by four themes: challenge, control, frustration, and relationships. These findings indicate that district nurses must be offered resources and education in order to be able to fulfill their commitment, i.e. , to supply good palliative care.
Family distress in palliative medicine: A pilot study of the Family APGAR Scale
Authors: Powazki Ruth D. , Walsh Declan
Published: May 2006

The family is essential to patients with advanced cancer. Family and caregiver distress, however, can impair optimal care and support of the patient. A five-item questionnaire, the Family APGAR Scale, was evaluated to determine family functioning levels of selected patients. The APGAR Scale has five components for measuring family functioning: Adaptation, Partnership, Growth, Affection, and Resolve. Fifty consecutive patients admitted to a palliative medicine inpatient unit were reviewed for a pilot study. Eligibility requirements included admission to the unit for the first time, and the ability to speak English and give informed consent. Fifteen patients and 11 primary care-givers participated. Despite the small sample, some significant family functioning issues were identified. Completing the study later with a larger sample will provide information that will help the multidisciplinary team better meet the needs of both patient and family.
Audit tools for palliative care services: Identification of neglected aspects of care
Authors: Charlton Rodger , Smith Gary , White David , Austin Carol , Pitts Marian
Published: May 2006

The purpose of this study was to investigate the extent to which audit of palliative care service occurs nationally in Britain and Ireland. The following items were measured: (1) audit tools employed, (2) aspects of services undergoing audit, (3) changes in practice as a result of audit, and (4) obstacles to conducting some aspects of the audit. Audit practices were surveyed by means of a postal questionnaire distributed to managers of all hospice and palliative care services in the United Kingdom and Republic of Ireland. A 10 percent sample of managers (n = 40) who responded were subsequently interviewed to confirm and elaborate on questionnaire responses. The response rate was 60 percent and was highest for hospices at 68 percent. Of the respondents, 73 percent audit their services. Of those who audit their services, 79 percent changed their service as a result. Although physical aspects of care were audited frequently (61 percent), other core aspects of palliative care that rarely were audited included bereavement care (17 percent), training (13 percent), and psychological and spiritual care (12 percent). Managers indicated that some aspects of care were rarely audited because they considered clinical and organizational aspects of palliative care to be more important. They also stated that they did not have enough time, expertise, or adequate measurement tools. Until the neglected features of palliative care are audited, the full effectiveness of the services remains unknown.
Parallels in practice: Palliative nursing practice and Parse’s theory of human becoming
Authors: Hutchings Deanna
Published: May 2006

Nurses experienced in the art and science of palliative nursing will find many elements of congruence between the principles and philosophy of palliative practice and the theory of human becoming. In this brief exploration of parallels in practice between Parse’s theory of human becoming and traditional palliative and hospice nursing practice, the author suggests that the theory of human becoming is consistent and consonant with the values that shape palliative nursing practice. The theory is briefly described, and four parallels of practice are identified: whole person care; the presence of paradox in human experience; primacy of the person; and presence and dialogue, or “being with,” dying persons. The theory of human becoming holds relevance and promise in its capacity to provide palliative and hospice nurses with a theoretical framework with which to inform and guide nursing practice with dying persons.
Multidimensional continuous pain assessment chart (MCPAC) for terminal cancer patients: A preliminary report
Authors: Bercovitch Michaela , Waller Alexander , Adunsky Abraham
Published: May 2006

Current use of pain measures is limited in clinical practice. The common pain measures neither target nor monitor the changes that occur with time with regard to the effect of other parameters associated with pain control. Changes in parameters, such as pain type, various pharmacological and nonpharmacological interventions, dosage of medications, and use of rescue doses, usually complicate pain control in terminal cancer patients. The authors propose use of a multidimensional, continuous pain chart that permits better assessment and control of pain. The chart integrates visual analogue pain assessment, special treatment techniques, regular medications and rescue doses, co-analgesics, pain categories, parameters relating to quality of life, sleep, and mobility. A total of 1,178 assessments were performed in 100 consecutive patients with full compliance. The chart permitted a continuous monitoring of patients’ most important needs concerned with pain control and was easily integrated into the hospice daily routines. We conclude that the chart represents an effective and friendly graphic tool to monitor pain and associated parameters that relate to the quality of the broad spectrum of pain control. The hope is that this tool may improve pain control by hospice professionals and facilitate communication between patients and the interdisciplinary team members.