Wednesday, 9 July 2008

Journal of pain and symptom management Apr 2008 vol. 35, no. 4

Bereaved family members' evaluation of hospice care: what factors influence overall satisfaction with services?
p. 365-71
Rhodes-Ramona-L, Mitchell-Susan-L, Miller-Susan-C, Connor-Stephen-R, Teno-Joan-M.
As patients near the end of life, bereaved family members provide an important source of evaluation of the care they receive. A study was conducted to identify which processes of care were associated with greater satisfaction with hospice services from the perception of bereaved family members. A total of 116,974 surveys from 819 hospices in the United States were obtained via the 2005 Family Evaluation of Hospice Care, an online repository of surveys of bereaved family members' perceptions of the quality of hospice care maintained by the National Hospice and Palliative Care Organization. Overall satisfaction was dichotomized as excellent vs. other (very good, good, fair, and poor). Using multivariate logistic regression, the association between overall satisfaction and the individual item problem scores that compose the Family Evaluation of Hospice Care were examined. Bereaved family members were more likely to rate overall satisfaction with hospice services as excellent if they were regularly informed about their loved one's condition (adjusted odds ratio (AOR)=3.76, 95% confidence interval (CI)=3.61-3.91), they felt the hospice team provided the right amount of emotional support to them (AOR=2.21, 95% CI=2.07-2.38), they felt that the hospice team provided them with accurate information about the patient's medical treatment (AOR=2.16, 95% CI=2.06-2.27), and they could identify one nurse as being in charge of their loved one's care (AOR=2.02, CI=1.92-2.13). These four key processes of care appear to significantly influence an excellent rating of overall satisfaction with hospice care.

The potential role of zuclopenthixol acetate in the management of refractory hyperactive delirium at the end of life.
p. 336-9
Tarumi-Yoko, Watanabe-Sharon.
Case-Reports, Letter.

Clinical and economic impact of palliative care consultation.
p. 340-6
Hanson-Laura-C, Usher-Barbara, Spragens-Lynn, Bernard-Stephen.
Palliative care consultation is the most common model of hospital- based services in the United States, but few studies examine the impact of this model. In a prospective study, we describe the impact of palliative care consultation on symptoms, treatment, and hospital costs. Patients receiving interdisciplinary palliative care consultations from 2002 to 2004 were approached for enrollment; 304 of 395 (77%) patients participated. Measures included diagnosis, treatment decisions, and symptom scores. To test impact on costs, a one-year subset of cases with lengths of stay >4 days (n=104) was compared to all available controls (n=1,813) matched on the 3Mtrade mark All Patients Refined Diagnosis Related Group, Version 20, and mortality risk scores. Half of the patients were younger than 65 years, 28% were African American, and 61% had cancer. Median Palliative Performance score was 20 (range, 10-100). Recommendations were implemented in 88% of cases; new do not resuscitate/do not intubate orders were written for 34% of patients, new comfort care orders for 44%, and 27% were referred for hospice care. Symptom scores improved from Day 1 to Day 3, with greatest improvement in pain (2.6-1.4, P<0.001). p="0.03).">50% hospital days with palliative care consultation. Palliative care consultation is followed by decisions to forego costly treatment and improved symptom scores, and earlier palliative care intervention results in greater cost-savings.

Screening for discomfort as the fifth vital sign using an electronic medical recording system: a feasibility study.
p. 430-6
Morita-Tatsuya, Fujimoto-Koji, Namba-Miki, Kiyohara-Emi et al
Late referral to a specialized palliative care service hinders quality symptomatic management. The aim of this article is to describe the feasibility and clinical usefulness of screening for patient discomfort as the fifth vital sign using an electronic medical recording system to identify patients with undertreated physical symptoms. For the electronic medical recording system, all admitted patients received routine nurse assessment of discomfort (defined as any physical symptom) at every vital signs check using Item 2 of the Support Team Assessment Schedule Japanese version (STAS). All medically treated cancer patients admitted to seven oncology units were automatically screened at one-week intervals. Positive screening was defined as a STAS score of 2 or more at least two times during the previous week. For each patient identified by screening, a palliative care team reviewed the medical record and provided written recommendations when other treatments might improve the patient's physical symptoms. Of 629 patients screened, 87 (14%) initially met the positive screening criteria. Fifteen (17%) were false positive due to psychiatric symptoms without physical symptoms or due to misrecording. Of 72 cases with actual discomfort, 33 had already been referred to the palliative care team, 14 had received adequate palliative care as determined by the palliative care team, 14 had self-limiting transient discomfort, and one patient died before the screening day. In the remaining 10 cases (11% of symptomatic patients, 1.7% of all screened patients), the palliative care team recommended potentially useful interventions for symptom control; seven patients were referred to the palliative care team within one week. The time required for all screening processes was about 30 minutes per week. This experience demonstrates that screening for patient discomfort as the fifth vital sign using an electronic medical recording system can be successfully implemented and may be useful in facilitating early referral of distressing patients to the specialized palliative care service.

I will do it if it will help others: motivations among patients taking part in qualitative studies in palliative care.
p. 347-55
Gysels-Marjolein, Shipman-Cathy, Higginson-Irene-J.
The aim of this study was to explore patients' and carers' preferences and expectations regarding their contribution to research in palliative care through the use of qualitative interviews. Data were collected in the context of two studies exploring the experiences of care of palliative care patients and carers. Both studies recorded the recruitment process, numbers of patients or carers accepting and declining, and the circumstances of interviews. Participants were asked about their motivation to participate in research. The data were analyzed by labeling patients' reflections on their motivations for participating in these studies and identifying themes. Analysis of the recruitment process revealed differential patterns in decline and acceptance of interviews by patients with different conditions and across settings. Among cancer patients, 21 /51 declined; the proportion with other conditions that declined was small, and was 0/10 for patients with motor neuron disease. Motivation to participate in the studies was related to (1) altruism, (2) gratitude and concerns about care, (3) the need to have somebody to talk to, and (4) the need for information or access to services. Palliative care patients and carers were capable of deciding whether to participate in interviews and negotiating how they wanted this to happen. This strengthens the argument for patients' autonomy in deciding whether to participate in research. Patients and carers have different motivations for participation, reflecting the heterogeneity of the palliative care population. This suggests a need for ethics committees to reconsider their views and widen their perspectives on the involvement of palliative care patients and carers in research.

The Schedule for Meaning in Life Evaluation (SMiLE): validation of a new instrument for meaning-in-life research.
p. 356-64
Fegg-Martin-J, Kramer-Mechtild, L-hoste-Sibylle, Borasio-Gian- Domenico.
The Schedule for Meaning in Life Evaluation (SMiLE) is a respondent- generated instrument for the assessment of individual meaning in life (MiL). In the SMiLE, the respondents list three to seven areas that provide meaning to their lives before rating the current level of importance and satisfaction of each area. Indices of total weighting (IoW; range, 20-100), total satisfaction (IoS; range, 0-100), and total weighted satisfaction (IoWS; range, 0-100) are calculated. The objective of this study was to assess the feasibility, acceptability, and psychometric properties of this newly developed instrument in its German and English versions. A total of 599 students of the Ludwig- Maximilians University, Munich and the Royal College of Surgeons, Dublin, took part in the study (response rate, 95.4%). The mean IoW was 85.7+/-9.4, the mean IoS was 76.7+/-14.3, and the mean IoWS was 77.7+/-14.2. The instrument was neither distressing (1.3+/-1.9) nor time-consuming (1.9+/-1.9), as assessed by numeric rating scales (range, 0-10). Test-retest reliability of the IoWS was r=0.72 (P<0.001); 85.6% of all areas were listed again after a test-retest period of seven days. Convergent validity was demonstrated with the Purpose in Life test (r=0.48, P<0.001), the Self-Transcendence Scale (r=0.34, P<0.001), and a general numeric rating scale on MiL (r=0.53, P<0.001). There was no correlation of the SMiLE with the Idler Index of Religiosity. Preliminary data indicate good feasibility and acceptability of the SMiLE in palliative care patients. The psychometrics of the SMiLE are reported according to the recommendations of the Scientific Advisory Committee of the Medical Outcomes Trust. Descriptors MODELS-PSYCHOLOGICAL/*; PALLIATIVE-CARE/*PX (psychology); PSYCHOMETRICS/*MT (methods), *ST (standards); VALUE-OF-LIFE/*. ATTITUDE; HUMANS; PERSONAL-SATISFACTION; REPRODUCIBILITY-OF-RESULTS. Language English. Publication type Journal-Article, Research-Support-Non-US-Govt, Validation-Studies. Journal subset IM. Country of publisher United-States. Journal code 0008605836. Information provider NLM. Notes Publication model: Print-Electronic; Cited medium: Print; ISSN: Print. Publication year 2008. Publication date 20080400. Entry date Date created: 20080324 Date completed: 20080618. (COPYRIGHT BY National Library of Medicine, Bethesda MD, USA)

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