Inpatient Hospice Care Research Articles

A New Italian Questionnaire to Assess Caregivers of Cancer Patients' Satisfaction With Palliative Care: Multicenter Validation of the Post Mortem Questionnaire-Short Form

ContextCaregiver satisfaction with palliative care is a crucial indicator of its effectiveness. In light of the lack of validated or reliable Italian instruments, the Post Mortem Questionnaire-Short Form (QPM-SF), a self-report questionnaire, has been developed to assess home and inpatient hospice care. ObjectivesThe present study was designed to evaluate the psychometric properties of QPM-SF and assess for differences in quality of palliative care between hospice and home care settings. MethodsA total of 584 caregivers of terminal cancer patients completed QPM-SF one month after the death of the care recipient. To assess test-retest reliability, a subgroup of 50 caregivers completed the questionnaire a second time, one month later. ResultsQPM-SF showed good internal consistency and temporal stability and a four-factor structure: “Integrated home care,” “Hospice,” “Physical care-Information-Global evaluation,” and “Needs.” ConclusionQPM-SF may be considered a valid, reliable, and well-accepted self-report instrument for examining and implementing palliative care interventions.

The COPE Intervention for Caregivers of Patients With Heart Failure

The purpose of this 2-group comparative experimental study was to pilot test the heart failure–COPE (creativity, optimism, planning, and expert information) intervention for caregivers of heart failure patients in hospice care in a small randomized trial focusing on caregiver burden, quality of life, depression and anxiety, caregiver knowledge, patient quality of life, and emergency room visits and hospitalizations. Forty patient-caregiver dyads participated with the treatment group receiving the COPE–heart failure intervention in 21 days, and both groups provided data at baseline and at weeks 4 and 5. Results showed no effect of the intervention, but the sample was small, and patients had been diagnosed for a mean of more than 10 years. The most commonly reported symptoms by patients were dry mouth and fatigue. Self-care was less than adequate, but depression and distress among patients were low, whereas quality-of-life scores were relatively high. Caregivers reported low distress from patient symptoms and from caregiving burden and low mean anxiety and depression scores. We concluded that caregivers had been managing heart failure symptoms for a long time and that our intervention near the end of the disease trajectory was not needed; caregivers already felt competent to manage the care of these patients.

Bereavement among Hospice Caregivers of Cancer Patients One Year following Loss: Predictors of Grief, Complicated Grief, and Symptoms of Depression

Informal caregivers are an integral part of end-of-life care for hospice patients with cancer. Although adjustment following loss is highly individual, many caregivers have significant psychological distress after the death of a loved one. This study investigated risk factors that may predict psychological distress, which could aid hospice bereavement departments in targeting bereavement services. Demographic characteristics, patient impairment, caregiver baseline symptoms of depression, and caregiver resources were assessed among 188 cancer patient-caregiver dyads. Regression analyses identified predictors of symptoms of depression, grief, and complicated grief one year following loss. Over 50% of bereaved caregivers had clinically significant depressive symptoms one year after death of their relative. Caregivers with fewer years of education and more baseline symptoms of depression had significantly worse grief, complicated grief, and depression. Younger patient age was a significant predictor of poorer outcomes for grief and complicated grief; and less patient impairment was a significant predictor of more post-loss symptoms of depression. Lower social support satisfaction was correlated with worse grief and complicated grief but was not a significant multivariate predictor of poorer outcomes. Despite having access to hospice bereavement services, many former caregivers had high psychological distress one year following loss. Bereavement departments could consider utilizing readily available risk factors to target services to former caregivers who may benefit from bereavement services. Bereavement departments might also consider including brief, standardized screenings of caregiver depression in initial risk assessments. Future studies should investigate evidence-based approaches for assessment and interventions among highly distressed former hospice caregivers.

Hospice Offers More Palliative Care but Costs Less Than Usual Care for Terminal Geriatric Hepatocellular Carcinoma Patients: A Nationwide Study

Hospice care is important for patients with terminal hepatocellular carcinoma (HCC), especially in endemic areas of viral hepatitis. Differences between hospice care and usual care for geriatric HCC inpatients have not yet been explored in a nationwide survey. The study's purpose was to analyze differences between hospice care and usual care for geriatric HCC inpatients in a nationwide survey. This nationwide, population-based study used data obtained from the Taiwan National Health Insurance Database. Patients with terminal HCC who were ≥65 years old and received their end-of-life care in the hospital between January 2001 and December 2004 were recruited. The comparison group was selected by propensity score matching from patients receiving usual care in acute wards. We enrolled 729 terminal HCC patients receiving inpatient hospice care and 729 matched controls selected from 2482 HCC patients receiving usual care. Hospice care patients were treated mainly by family medicine doctors (36%) and oncologists (26%), while usual care patients were treated mainly by gastroenterologists (60.2%). The natural opium alkaloids were used more in the hospice care group than in the usual care group (72.7% versus 25.5%, P<0.001), whereas the length of stay (8±7.7 days versus 14.1±14.3 days, P<0.001), aggressive procedures (all P<0.005), and medical expenses (all P<0.001) were significantly less in the hospice care group. HCC patients in hospice wards received more narcotic palliative care, underwent fewer aggressive procedures, and incurred lower costs than those in acute wards. Hospice care should be promoted as a viable option for terminally ill, elderly HCC patients.

Effective Pain Management of Older Adult Hospice Patients With Cancer

Pain is subjective and a unique and individual experience. For those involved in the care of hospice patients, pain management can be challenging and is not always effectively managed. This case study explores an older adult cancer patient's pain experience at the end of her life with implementation of pain management strategies from hospice.

End-of-life experiences and expectations of Africans in Australia

The ageing and frail migrants who are at the end of life are an increasing share of migrants living in Australia. However, within such populations, information about end-of-life experiences is limited, particularly among Africans. This article provides some insights into the sociocultural end-of-life experiences of Africans in Australia and their interaction with the health services in general and end-of-life care in particular. It provides points for discussion to consider an ethical framework that include Afro-communitarian ethical principles to enhance the capacity of current health services to provide culturally appropriate and ethical care. This article contributes to our knowledge regarding the provision of culturally appropriate and ethical care to African patients and their families by enabling the learning of health service providers to improve the competence of palliative care systems and professionals in Australia. Additionally, it initiates the discussion to highlight the importance of paying sufficient attention to a diverse range of factors including the migration history when providing palliative and hospice care for patients from African migrant populations.

A Retrospective Chart Review of the Efficacy of Ketamine for Depression in Patients Receiving Hospice Care (FR416-A)

1.Understand the importance of treating depression in patients receiving hospice care.2.Understand why standard antidepressants are not adequate for this patient population.3.Understand the efficacy and tolerability of ketamine for the treatment of depression in inpatients receiving hospice care. Depression is highly prevalent in patients receiving hospice care and untreated depression is associated with poor outcomes. Standard antidepressant medications often do not work rapidly enough for patients receiving hospice care. A growing body of literature suggests ketamine may rapidly treat “treatment refractory depression” in the general population. However, ketamine's role in treating depression in the hospice population is not well understood. A retrospective chart review of inpatients receiving hospice care who received ketamine for treatment of their depression was conducted to examine efficacy, time to efficacy, and tolerability of ketamine for treatment of depression. 31 patients' charts were reviewed and evaluated for severity of depression, global improvement, therapeutic effect, side effects, and efficacy of treatment based on the Clinical Global Impression Scale (CGI). Time to onset of therapeutic effect, maximal effect and side effects were also documented. CGI scores from days 1, 3, 7, and 14-21 days post-ketamine dosing were compared by Chi-squared analyses. Chi-squared analyses were also utilized to compare both time to first therapeutic effect and maximum effect between different time points post-ketamine dosing. Significantly more patients experienced their first therapeutic response (χ2 = 25.5, df = 4, p < 0.001) and maximal response (χ2 = 14.5, df = 7, p = 0.043) to ketamine day 1 post-ketamine dosing. Additionally, significantly more patients had a marked therapeutic response (p < .011), rather than unchanged, minimal, or moderate therapeutic response, to ketamine days 1 and 3 post-ketamine dosing. Significantly more patients were rated as having no side effects (p < .002) compared to those having minimal, moderate, marked, or severe side effects. This data suggests that for depressed patients receiving inpatient hospice care, ketamine is well tolerated and has a rapid onset of action and is safe and efficacious.

Current state of palliative and end-of-life care in home versus inpatient facilities and urban versus rural settings in Africa

Because palliative care in sub-Saharan Africa may not fit the style of delivery of palliative care in the global north, exploring the evidence can serve to reduce existing barriers and help streamline national policies that determine the optimal setting to implement formal palliative and end-of-life services. A search was conducted in Ovid MEDLINE®, PubMed, and Google Scholar databases using the search terms nursing care, terminal care, end of life care, palliative care, dying, death, hospice, opioids, morphine, Africa, sub-Saharan Africa, caregivers, and place of death. Eighty-seven relevant articles were found using the search terms. Of these, 22 matched inclusion criteria and were reviewed. Opioid availability and distribution is best accessed at the inpatient level, and hence, pain and end-of-life symptoms are best managed at the inpatient level. Despite the great need, nurses' lack of prescription power in the home-based setting is a shortcoming. Home deaths have not been adequately studied, but research suggests that palliative care generally causes economic strain, psychosocial distress on family members, and increased risk of transmission of communicable disease. Hospice is understudied but shows favorable outcomes. Funding and research need to focus on development of inpatient palliative and hospice care units in urban areas. In rural areas, the priority should be a home-based care model that involves nurses who are privileged to prescribe opioids and adjunctive medication therapies.

Ethics Commentary: Ethical Issues in Geriatric Psychiatry

By 2030, due to the aging of the baby boomers, the U.S. Census Bureau predicts that nearly one in five people will be 65 or older—a substantial increase from the 13% of the population that was 65 or older in 2010. This population of older adults is projected to have increased needs for mental health care, which the current workforce is inadequate to meet (1, 2). For example, by the year 2050, an estimated 13 million adults will suffer from Alzheimer’s disease (AD) (3). Many of these individuals will develop behavioral and psychological symptoms as their disease progresses. Depressive disorders remain underdetected in older adults, and despite years of attention to the issue of undertreatment of depression in the older adult population, this continues to be a problem (1, 4). Ongoing stigma about mental health treatment on the part of patients, as well as misconceptions and inadequate training regarding depression on the part of health care providers, likely contribute to the lack of identification and treatment of depressive disorders in older adults (5). Thus, although many older adults will age “successfully,” with intact cognition and stable mental health, a substantial minority will experience new onset psychiatric disorders, recurrence of disorders that initially developed earlier in life, or psychiatric manifestations of neurologic and medical disorders and their treatment. Special ethical challenges emerge at the intersection of aging, comorbidmedical illnesses, and psychiatric illnesses. Although a complete discussion of these issues is beyond the scope of this column, two topics that have received relatively little attention in the literature—financial exploitation and ethical issues in hospice care for patients with psychiatric disorders—will be discussed through the use of case examples.

Symptoms Experienced by Heart Failure Patients in Hospice Care.

End-stage heart failure patients are a prevalent hospice population with unique symptoms. The purpose of this study was to describe the frequency, severity, and distress of symptoms experienced by heart failure patients receiving hospice care. The relationships among depressive symptoms and symptom prevalence, severity, and distress were also examined. Forty patients with end-stage heart failure in hospice provided demographic information and responses to the Memorial Symptom Assessment Heart Failure Scale and the Profile of Mood States-Depression Scale. Patients reported experiencing a mean of 12.1 symptoms (range, 0-32). The most prevalent symptoms reported were dry mouth (72.5%), lack of energy (70%), and shortness of breath (65%). Symptom prevalence was not indicative of symptom severity and/or distress. Patients endorsed an average of 8 depressive symptoms (range, 0-10). Moreover, most end-stage heart failure patients indicated that they remained hopeful. The findings of the research underscore a need for further research into the symptoms experienced by end-stage heart failure patients in hospice to optimize symptom management by clinicians.

Symptoms Experienced by Heart Failure Patients in Hospice Care

Symptoms Experienced by Heart Failure Patients in Hospice Care

PROGRAM OF PALLIATIVE CANCER CARE – OUR EXPERIENCE

Annually more than 27,000 persons die of cancer in the Czech Republic and the overall incidence of malignancies is still increasing. These data shows the need for affordable and good follow-up care especially for patients without any cancer treatment due to irreversible progression of tumor. Currently the outpatient palliative cancer care gets more into the forefront. Prerequisite for a well working outpatient palliative care is cooperation with general practitioners and home health care agencies. The purpose of the so called program of palliative cancer care is to guide a patient in palliative cancer care and to improve the cooperation among health care providers. During the period from January 2008 to October 2010 we evaluated in patient without any oncology treatment due to irreversible progression of tumor. In palliative outpatient clinic we treated 446 patients, 119 of them received home care services with average length of 27.8 days. 77 patients died at home, 51 in health facilities and 41 in inpatient hospice care. We present pilot study focusing on outpatient palliative cancer care which shows the real benefit from early indication of palliative cancer care. This type of care allows patients to stay as long as possible at home among their close relatives.

A Qualitative Review of Occupational Therapists' Listening Behaviors and Experiences When Caring for Patients in Palliative or Hospice Care

Listening behaviors and experiences of occupational therapists working with patients in palliative or hospice care were investigated. Because the U.S. Government's Healthy People 2020 mandates better listening in health care, this research is timely. A qualitative design using semi-structured interviews and member checks provided researchers with rich text that revealed patterns and themes associated with listening behaviors, listening experiences, and listening training of occupational therapists working in palliative and hospice care. Participants were selected using typical case and snowball sampling. Six participants from two distinct geographic regions of the United States agreed to be interviewed. Interviews revealed four themes: working within the OT Practice Framework, key listening behaviors used in this context, listening barriers and challenges, and clinical competence and training needed prior to working with this population. This small sample size represents only a fraction of the occupational therapists working in palliative or hospice care, yet provides a foundation for further research and underscores the importance of listening behaviors.

Hospice nurses' perceptions of caring for patients with a non-malignant diagnosis: a single-site case study

In the early stages of its development in the UK, palliative care focused almost exclusively on the care of patients with cancer, with efforts concentrated on relieving distressing physical symptoms in the last few weeks of life-often referred to as terminal care. It is increasingly expanding to include non-malignant conditions, but is still predominantly accessed by cancer patients. This paper presents findings from a small-scale qualitative study into nurses' experiences of providing hospice care for patients with a non-malignant diagnosis. Two focus groups were conducted with nurses in one established UK hospice. The results highlight the importance of timely educational preparation, the need for proactive thinking regarding the shifting medical profiles of health care in the UK, and the need for hospice managers to critically consider existing infrastructures (including supervision and support) in anticipation of diverse patient populations. The paper also reiterates that collaboration remains the key to effective support.

Morphine and Hydromorphone-Induced Hyperalgesia in a Hospice Patient

Opioids including morphine and hydromorphone are widely used for control of moderate to severe pain and dyspnea in hospice and palliative care patients. Accumulation of the active morphine-3-glucuronide (M3G) and hydromorphone-3-glucuronide (H3G) metabolites is one proposed mechanism for the development of neuroexcitatory effects including allodynia and opioid-induced hyperalgesia (OIH). We report the case of a 43-year-old female hospice patient with metastatic non-small cell lung cancer who initially developed allodynia following morphine administration and again following administration of hydromorphone. The allodynia resolved both times following the discontinuation of the opioid and rotation to a different opioid regimen. Potential opioid-induced neuroexcitatory treatment options include opioid rotation to an agent with inactive metabolites, use of adjuvant pain medications for opioid-sparing effects, management of undesired symptoms (e.g., myoclonus), or increasing opioid clearance with intravenous (IV) fluids. Although the incidence is not well defined in the literature, hospice and palliative care clinicians should suspect OIH in patients with allodynia and/or hyperalgesia, especially when repeated dose escalations do not improve analgesia or pain escalates following opioid dose titration.

Development and Evaluation of a Palliative Medicine Curriculum for Third-Year Medical Students

To assess the impact, retention, and magnitude of effect of a required didactic and experiential palliative care curriculum on third-year medical students' knowledge, confidence, and concerns about end-of-life care, over time and in comparison to benchmark data from a national study of internal medicine residents and faculty. Prospective study of third-year medical students prior to and immediately after course completion, with a follow-up assessment in the fourth year, and in comparison to benchmark data from a large national study. Internal Medicine Clerkship in a public accredited medical school. Five hundred ninety-three third-year medical students, from July 2002 to December 2007. Pre- and postinstruction performance on: knowledge, confidence (self-assessed competence), and concerns (attitudes) about end-of-life care measures, validated in a national study of internal medicine residents and faculty. Medical student's reflective written comments were qualitatively assessed. Required 32-hour didactic and experiential curriculum, including home hospice visits and inpatient hospice care, with content drawn from the AMA-sponsored Education for Physicians on End-of-life Care (EPEC) Project. Analysis of 487 paired t tests shows significant improvements, with 23% improvement in knowledge (F(1,486)=881, p<0.001), 56% improvement in self-reported competence (F(1,486)=2,804, p<0.001), and 29% decrease in self-reported concern (F(1,486)=208, p<0.001). Retesting medical students in the fourth year showed a further 5% increase in confidence (p<0.0002), 13% increase in allaying concerns (p<0.0001), but a 6% drop in knowledge. The curriculum's effect size on M3 students' knowledge (0.56) exceeded that of a national cross-sectional study comparing residents at progressive training levels (0.18) Themes identified in students' reflective comments included perceived relevance, humanism, and effectiveness of methods used to teach and assess palliative care education. We conclude that required structured didactic and experiential palliative care during the clinical clerkship year of medical student education shows significant and largely sustained effects indicating students are better prepared than a national sample of residents and attending physicians.

An Examination of Adherence to Pain Medication Plans in Older Cancer Patients in Hospice Care

ContextTimely and appropriate management of pain is essential to promote comfort at the end of life. ObjectivesTo determine if pain-related factors and nonpharmacologic interventions affect medication adherence in older cancer patients in community-based hospices. MethodsThe study involved cancer patients aged 55 years and older, newly admitted to one of the 13 community-based hospices in the midwestern U.S. A descriptive design with patients or their proxies providing information during two telephonic interviews and review of their hospice medical records were used. ResultsA total sample of 65 patients was obtained, with data directly from 32 patients during Interview 1 (T1), 25 during Interview 2 (T2), and proxy reports for 33 (T1) and 30 (T2) patients. The overall mean pain medication adherence scores (maximum 9) for all patients were 8.43 (T1) and 8.38 (T2). For component analysis (three components; maximum of three points each), patients were the least adherent with opioid orders at both time points (2.65). Patients were the most adherent to nonsteroidal anti-inflammatory/acetaminophen orders at T1 (2.91) and medications for neuropathic pain at T2 (2.89). Data provided statistical evidence that patients with more hours of controlled pain in the past 24 hours were more likely to have had better adherence, whereas patients with higher levels of comfort over the last few days were more likely to have had worse adherence. ConclusionThis study identified that pain medication adherence among older adults with cancer receiving hospice care is high. However, hospices must be alert to the fact that even as patients become more comfortable, adherence must continue to be emphasized to ensure that pain does not redevelop or exacerbate, if pain relief is a patient priority.

A Descriptive, Retrospective Study of After-hours Calls in Hospice and Palliative Care

AIMS: Few studies have described after-hours calls in hospice patient care. This retrospective study examines the timing of after-hours telephone triage services; the reasons for access to after-hours hospice and palliative care services; and the predominant nursing interventions offered in after-hours calls in hospice and palliative care. METHODS: A fixed coding scheme was used to code a de-identified after-hours triage phone log of all calls between July 2005 and June 2006 (n=4,434) from a Pennsylvania hospice and palliative care services organization. Descriptive statistics were used to identify call timing pattern, call reasons, and predominant nursing interventions. RESULTS: Triage services were utilized most frequently to request assistance with signs and symptoms control (25.7%), report death (17.8%), and to request a home visit (15.3%). The top nursing interventions included updating case managers or supervisors about the needs of follow-up (29.5%), coordinating home visits (20.5%), and instructing caregivers or patients on how to control new signs and symptoms (19.8%). CONCLUSIONS: A better understanding of when and why patients and their family caregivers utilize after-hours hospice triage services can assist in the design of future proactive interventions to improve care, and enhance training for new and existing hospice triage nurses.

What Is Special about Patients with Lung Cancer and Pulmonary Metastases in Palliative Care? Results from a Nationwide Survey

Patients with advanced lung cancer constitute a special focus in palliative care not only for epidemiological or prognostic reasons, but also because their symptom burden is felt to be widespread and difficult to treat. This study describes disease-specific characteristics and the symptom burden of patients with advanced incurable lung cancer, comparing them with patients suffering from other diseaseentities. A secondary analysis of the nationwide Hospice and Palliative Care Evaluation (HOPE) was performed, by focussing on inpatient hospice and palliative care unit patients and by using descriptive methods. From 2006 to 2008, 5487 inpatients were registered, 874 of which were diagnosed with lung cancer and 1884 with pulmonary metastases. Symptoms such as weakness, tiredness, or pain were most prevalent in all subgroups. Dyspnea was significantly more prevalent in all patients with different kinds of pulmonary tumor manifestations; confusion was significantly more prevalent in patients with lung cancer. Dyspnea could not be treated as effectively as pain or nausea. Confusion and nursing problems worsened during the observation period. Dyspnea and confusion were associated with increased risk of death during the observational period. The symptom pattern of patients with lung cancer is characterized by dyspnea and confusion--symptoms that are difficult to treat until discharge and that imply a worse prognosis. Therefore, increased research on the pathophysiology and treatment of dyspnea and confusion is required, and efforts in advance care planning and anticipation of dyspnea and confusion as a critical symptom in patients with lung cancer should be reinforced.

Federal showdown in Florida

Federal showdown in Florida