American Journal of Hospice and Palliative Medicine current issue

Nurses' Perceptions of Hospice Palliative Care Volunteers

Claxton-Oldfield, S., Hastings, E., Claxton-Oldfield, J. — 2008-06-23

A total of 50 nurses (hospital and home care) responded to a survey designed to measure: (1) their attitudes toward, and knowledge of, hospice palliative care volunteers; (2) the types of tasks they felt it was appropriate for volunteers to perform; and (3) how valuable they felt different members of the hospice palliative care team are. In addition, they were asked to respond to some open-ended questions (eg, "Do you feel that it is appropriate for hospice palliative care volunteers to know patient medical information?"). The nurses' responses to the "Attitude/Knowledge" part of the survey revealed that they generally held positive attitudes toward volunteers. The majority of the nurses felt that it was appropriate for volunteers to perform most of the tasks listed, except for hands-on patient care. Nurses rated the value of nurses, family members, doctors, and pharmacists significantly higher than volunteers. Fifty-three percent of the nurses felt that volunteers should know patient medical information, and 77% thought that volunteers should have the opportunity to provide input regarding patient care. Also, 75% of the nurses felt that volunteers made their jobs easier, and 56% felt that volunteers should be included in team meetings. When asked to list the topics covered in a hospice palliative care volunteer training program, 73% of the nurses indicated that they were not sure or did not know what topics were covered, indicating a lack of knowledge regarding volunteer training.

Use of Advance Directives for Nursing Home Residents in the Emergency Department

Weinick, R. M., Wilcox, S. R., Park, E. R., Griffey, R. T., Weissman, J. S. — 2008-06-23

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.

Efficacy of a Scheduled IV Cocktail of Antiemetics for the Palliation of Nausea and Vomiting in a Hospice Population

Kumar, G., Hayes, K. A., Clark, R. — 2008-06-23

This is a retrospective analysis of 10 mg metoclopramide, 25 mg diphenhydramine, and 4 mg dexamethasone given intravenous piggyback every 6 hours for nausea or vomiting. Outcome measures were rapidity of symptom relief based on the self-report of the patient and nursing documentation of relief from symptoms of nausea or vomiting. Seven hundred and ninety seven patients were admitted to the inpatient hospice unit during a 2-year period. Sixty-three patients developed nausea or vomiting requiring the cocktail. Fifty-seven patients (90%) had objective response as reflected in nursing notes. Symptom relief was usually noted within 2 days with improvement in oral intake and enjoyment in activities, such as parties and family interactions. Partial relief was noted in patients with gastrointestinal malignancies and peritoneal carcinomatosis even with the addition of other antiemetics to the cocktail.

Residency Training in Advance Care Planning: Can It Be Done in the Outpatient Clinic?

Alderman, J. S., Nair, B., Fox, M. D. — 2008-06-23

Resident physicians are expected to assist their outpatients to understand and complete advance directives, but their efficacy in doing so remains uncertain. After receiving educational training, internal medicine residents identified at-risk patients and solicited them about advance directives. Residents completed pretest and posttest questionnaires that assessed their knowledge, skills, attitude, and comfort with advance directives. Patients were also surveyed about their attitudes regarding advance directives. Ten internal medicine residents and 88 patients participated. Residents' self-assessed knowledge rose from 6.0 to 9.2 on a 10-point Likert scale. Skills using advance directives increased from 4.0 to 7.9, attitudes improved from 6.0 to 8.4, and comfort rose from 5.4 to 8.9. Eighty-four percent of patients expressed interest in completing advance directives, and 16% actually completed documents. An educational intervention improved knowledge, skills, attitudes, and comfort with advance directives among internal medicine residents practicing in the outpatient setting. Meanwhile, patients demonstrated a strong interest in completing advance directives.

End-of-Life Experiences and the Dying Process in a Gloucestershire Nursing Home as Reported by Nurses and Care Assistants

Brayne, S., Lovelace, H., Fenwick, P. — 2008-06-23

This article presents an interim study into the end-of-life experiences of elderly residents in a Gloucestershire nursing home as reported by nurses and care assistants. It draws comparisons between the experiences of an end-of-life experiences pilot study conducted with the Camden Palliative Care Team in the United Kingdom with those of the nursing home staff to consider whether the dying experience of elderly nursing home residents is the same as those whose lives are foreshortened through terminal illness. It draws the conclusion that elderly residents have end-of-life experiences similar to those described in the Camden pilot study. It also examines the effect that end-of-life experiences have on the carers and reflects on possible needs for specialized training and support to deal with such existential issues.

Using the LCP: Bereaved Relatives' Assessments of Communication and Bereavement

2008-06-23

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. The authors studied whether use of the LCP affects relatives' retrospective evaluation of communication and their level of bereavement. An intervention study was conducted. During the baseline period, usual care was provided to dying patients. During the intervention period, the LCP was used for 79% of the patients. In total, bereaved relatives filled in a questionnaire for 57% of the patients, on average 4 months after death. In the intervention period, relatives had lower bereavement levels when compared with relatives in the baseline period (P = .01). Communication was evaluated similarly for both periods. We conclude that LCP use during the dying phase seems to moderately contribute to lower levels of bereavement in relatives.

Resolving End-of-Life Ethical Concerns: Important Palliative Care Practice Development Issues for Acute Medicine in Australia

McGrath, P., Henderson, D. — 2008-06-23

Historically palliative care research has focused on issues associated within the hospice and palliative care system. The findings presented in this manuscript reverse this assumption to argue that significant palliative care issues can only be understood if the focus is on the acute care system. Although a major proportion of deaths happen in the acute hospital setting, the acute care clinicians are the gate keepers to the palliative system. In short, understanding the ethical decision making of acute care professionals in relation to end-of-life care can illuminate many important palliative care practice development issues. The findings indicate that all professional groups in this study of an acute medical ward find end-of-life issues the most challenging of all the ethical challenges.

The Japan HOspice and Palliative Care Evaluation Study (J-HOPE Study): Study Design and Characteristics of Participating Institutions

Miyashita, M., Morita, T., Tsuneto, S., Sato, K., Shima, Y. — 2008-06-23

This article describes the study design and background data of participating institutions in the Japan HOspice and Palliative care Evaluation (J-HOPE) study. The J-HOPE study is a large nationwide survey about the dying experience of cancer patients. The primary aim of this article is to describe the design of the J-HOPE study for the bereaved family members of Japanese inpatient palliative care units and home hospices. Secondly, the aim was to describe characteristics of participating institutions. The authors conducted a cross-sectional questionnaire survey in 2007. One hundred Japanese inpatient palliative care units and 14 home hospices participated. The questionnaires were sent to 7955 bereaved family members of the Japanese inpatient palliative care units and 447 of the home hospices. The authors describe the structure of the Japanese inpatient palliative care units and home hospices, including type of staff, architectural structure, number of patients, and death. In addition, the authors describe available treatments at the Japanese inpatient palliative care units and home hospices.

End-of-Life Review

Aylor, A. L., Grimes, G. C. — 2008-06-23

Context: The term "End-of-Life Review" is often used by hospice workers in the context of spiritual apparitions or visitations prior to a patient's death. A review of the literature reveals no clear definition or categorization of this expression.

Objective: The aim of this study is to define the term "End-of-Life Review". Design: The study was performed using the Delphi method.

Setting/participants: A panel of interested parties was recruited from October 2006 to January 2007.

Intervention: Respondents were first asked to list their most common experiences associated with the term "End-of-Life Review," and then to rate each item as to how well it represented their understanding of this term. This process continued until subsequent rounds produce little change in the ranking of each item, suggesting a consensus. Conclusions: The term "End-of-Life Review" is a constellation of behaviors ranging from visitations from the departed to spiritual apparitions prior to death.

Management of Pericatheter Cerebrospinal Fluid Leak After Intrathecal Implantation of a Drug Delivery System

Singh, P. K., Jain, R., Mishra, S., Kumar, S., Bhatnagar, S., Deo, S. — 2008-06-23

Persistent cerebrospinal fluid leak is a known complication of intrathecal pump system insertion for drug delivery. Various treatment modalities, such as an epidural blood patch, use of glue, removal of catheter, and surgical closure of dura and subdural blood patch, have been reported previously. This report presents a 35-year-old woman in whom an intrathecal pump system was inserted for cancer pain management with intrathecal morphine. This was complicated by a persistent cerebrospinal fluid leak that was successfully managed by purse-string sutures over the dura around the catheter, without removing the intrathecal implant. The cause of the cerebrospinal fluid leak and different treatment approaches are discussed.

The Hospital-Survival and Prognostic Factors of Patients With Solid Tumors Admitted to an ICU

Mendoza, V., Lee, A., Marik, P. E. — 2008-06-23

The decision to admit a patient with cancer to the intensive care unit (ICU) is complex. There are limited data as to the outcome and prognostic factors of patients with solid tumors admitted to the ICU. A retrospective chart review was undertaken to evaluate this issue. Over an 18-month period, 147 patients with solid tumors were admitted to our ICU. Lung, colorectal, and breast were the commonest sites of the primary tumors, with 52% of patients having metastatic disease. A total of 79 (54%) patients survived to hospital discharge, with 50 (34%) patients being discharged to home. Metastatic disease and the requirement for vasopressor agents were independent predictors of poor outcome. The relatively high survival rate of this cohort of patients should prompt a reevaluation of the ICU admission criteria for patients with solid tumors who become critically ill.

Yet

Rousseau, P. — 2008-06-23

Review Article: Access to End-Of-Life Care Venues

Hallenbeck, J. — 2008-06-23

Quality of care at the end of life is strongly correlated with where patients die. This review discusses the influence of patient and health system variables affecting access to common venues of death-the acute care hospital, the nursing home, and home-with or without hospice. Access to care is considered in terms of a flow model, wherein pressure gradients push patients toward care in certain venues and away from alternatives. Dynamic interactions between patient-specific variables and health care system variables influence the nature of patient flow, moving patients toward certain terminal venues of care and away from others. Efforts to improve quality of care at the end of life must be cognizant of these effects and should work to adjust patterns of flow in more favorable directions.

Doreen and the Droopy Shoulder Syndrome

Clein, L. J. — 2008-06-23