Thursday 24 April 2008

BMC Palliative Care 2008, 7:3 (10 April 2008)

Use of a Cybex NORM dynamometer to assess muscle function in patients with thoracic cancer
Andrew Wilcock, Matthew Maddocks, Mary Lewis et al
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Journal of Hospice and Palliative Nursing 2008 ; Vol 10 ; Part 2

The Chronically Critically Ill : Opportunities for the Palliative Care Team
Koesel , N
From EBSCO ( CINAHL with Full Text ) - via Athens
Page:83-90
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Proving Palliative Care in End - Stage Heart Failure
Hemani , S . ; Letizia , M .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page:100-105
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Budgerigars can reduce stress .... in palliative care settings

Budgerigars can reduce stress and feelings of isolation for older patients in chronic or palliative care settings
Nursing Older People 2008 ; VOL 20 ; PART 3
From EBSCO ( CINAHL with Full Text ) - via Athens

Palliative care at the end of life

Palliative care at the end of life
Geriatrics 2008 ; VOL 63 ; PART 3 Access
Geriatrics From EBSCO ( CINAHL with Full Text ) - via Athens
Page:17

Palliative Care for Patients With Head and Neck Cancer

Palliative Care for Patients With Head and Neck Cancer : "I Would Like a Quick Return to a Normal Lifestyle"
Nathan E . Goldstein
JAMA 2008 ; VOL 299 ; PART 15 (2008-April-16)
JAMA - Journal of the American Medical Association
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International Journal of Palliative Nursing 2008 ; Vol 14 ; Part 3

Innovation : a core requisite for palliative nursing
Larkin , P
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 108-109
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Diagnosis and management of malignant spinal cord compression : part 1
Drudge - Coates , L ; Rajbabu , K .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 110-116
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The role of palliative care in supporting patients : a therapeutic community space
Fisher , C . ; O Connor , M . ; Abel , K .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 117-126
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Legalisation of euthanasia and assisted suicide : a professional's view
Gannon , C . ; Garland , E .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 127-131
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Nurses' management of patients with advanced cancer and weight loss : part 2
Dewey , A . ; Dean , T .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 132-138
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The benefits and drawbacks of syringe drivers in palliative care
Costello , J . ; Nyatanga , B . ; Mula , C . ; Hull , J .
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 139-144
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Palliative care professionals' perceptions of nutrition and hydration at the end of life
van der Riet , P . ; Good , P . ; Higgins , I . ; Sneesby , L .
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Page: 145-151
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The American journal of hospice & palliative care, Feb-Mar 2008, vol. 25, no. 1

Letter to the editor on: the impact of volunteering in hospice palliative care.
p. 74-5
Marchese-Kyrra-A.
Comment on: Am J Hosp Palliat Care. 2007 Aug-Sep; 24(4):259-63

The ethical concept of best interest.
p. 56-62
Baumrucker-Steven-J, Sheldon-Joanne-E et al

Gabapentin for intractable hiccups in palliative care.
p. 52-4
Tegeler-Monica-L, Baumrucker-Steven-J.
Abstract
Intractable hiccups are not common in the general population or in the palliative care population but can adversely impact quality of life and cause other complications such as weight loss and sleep disturbance. Many treatments have been proposed for intractable hiccups, but there is little consensus regarding treatment in the medical literature. This is partly because hiccups are relatively uncommon and many of the proposed treatments are unproven or have long-term side effects. Pharmacologic treatments rather than home remedies or surgical treatments are more appropriate for the palliative care patient. Gabapentin is a promising medication for the treatment of intractable hiccups for its safety, lack of serious side effects, and rapid onset of action. Further research is indicated to determine whether gabapentin is consistently effective.

A day in the life: a case series of acute care palliative medicine-- the Cleveland model.
p. 24-32
Lagman-Ruth, Walsh-Declan, Heintz-Jessica, Legrand-Susan-B, Davis- Mellar-P.
Abstract
Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.

Narrative accounts of volunteers in palliative care settings.
p. 16-23
Guirguis-Younger-Manal, Grafanaki-Soti.
Abstract
The long and evolving tradition of palliative care has always had a strong volunteer dimension. The difficult nature of palliative care invites questions around why volunteers choose this particular line of contribution. To expand our knowledge of the elements that create meaning and capture the essence of volunteer experience, we asked volunteers to share the rewards and the challenges of their work and its personal meaning. Significant themes emerged around what volunteers considered the most valuable aspects of their experience. Volunteers identified freedom of choice and the ability to use their natural gifts as an important condition for satisfaction. In addition, they perceived emotional resilience and personal hardiness as important dimensions of their suitability for working in palliative care. Finally, volunteers felt that their approach must be one of a balanced perspective, with an understanding of life and death as part of the human condition.

Identification of quality indicators of end-of-life cancer care from medical chart review using a modified Delphi method in Japan.
p. 33-8
Miyashita-Mitsunori, Nakamura-Asumi, Morita-Tatsuya, Bito-Seiji.
Abstract
End-of life care is one of the principle components of cancer care. Measurement of the quality of care provided for end-of-life cancer patients is an important issue. The aim of this study was to identify the quality indicators (QIs) for end-of-life cancer care for Japanese patients using a medical chart review. A modified Delphi method for the development of QIs was adopted. Seventeen multi-professional specialists participated by rating the appropriateness and feasibility of potential QIs. Thirty QIs for end-of-life cancer care were ultimately identified within 4 domains: (1) symptom control, (2) decision-making and preference of care, (3) family care, and (4) psychosocial and spiritual concerns. These QIs will be useful for monitoring and evaluating end-of-life care for Japanese cancer patients. The QIs are feasible for use in any clinical setting and cover a comprehensive area in accordance with the World Health Organization's (WHO) definition of palliative care including physical, psychosocial, and spiritual concerns.

Documentation in palliative care: nursing documentation in a palliative care unit-a pilot study.
p. 45-51
Gunhardsson-Inger, Svensson-Anna, Berteroe-Carina
Abstract
Palliative care seeks to enhance quality of life in the face of death by addressing the physical, psychological, social, and spiritual needs of patients with advanced disease. The purpose of this paper is to explore whether palliative patients' needs, nursing actions, and evaluation can be identified in the nursing documentation. Data consisted of reviews of patients' case records in a palliative care unit. Data were analyzed using content analysis and counting frequency of keywords used from the Well-being Integrity Prevention and Safety (VIPS) model, followed by an inductive analysis of the case record documentation aiming to identify palliative care components. The result shows that the documentation revealed physical care, especially pain, more frequently than other needs. Nursing documentation focuses on identification more than on nursing actions and evaluation.

A UK perspective on worldwide inadequacies in palliative care training: a short postgraduate course is proposed.
p. 63-71
Charlton-Rodger, Currie-Andy.
Abstract
A chronological literature review illustrates how undergraduate and postgraduate education and training in the care of the dying and bereaved is inadequate worldwide. This is despite the foundation of the modern hospice movement in the United Kingdom in 1967 and its wider dissemination as a specialty in 1985. This situation has implications for those doctors working in both primary and secondary care, and this paper describes a 3-day course which has been successfully run in the West Midlands, UK, since 1997 for family physicians in training. A pre-course survey of 250, with a response rate of 54%, in 2003 revealed that 100% of respondents felt that they needed further training, and 51.5% said that they had had no previous training in palliative care.

Confronting death: perceptions of a good death in adults with lung cancer.
p. 39-44
Hughes-Travonia, Schumacher-Mitzi, Jacobs-Lawson-Joy-M, Arnold- Susanne.
Abstract
Investigations regarding patients' concerns about death have focused on the importance of autonomy, resolution of concerns, family relationships, and religiosity, and relied on data from physicians, nurses, family members, and healthy older adults. Few studies have focused on patients with diseases that have short-term survival rates. This study examined lung cancer patients' perceptions of a good death. One hundred lung cancer patients answered open-ended questions about what a good death was and completed measures assessing coping, spirituality, religious coping, and life satisfaction. Content analysis revealed 4 themes describing a good death: (a) during sleep, (b) pain-free, (c) peaceful, and (d) quick. These findings have implications for those caring for terminally ill patients as the 4 themes differ from those derived from studies of more heterogeneous patients, their families, and health care providers.

A poor prognosis: guide or misleading?
p. 5-8
Wijnia-Jan-W, Corstiaensen-Inno-J-P-M.
Abstract
Patients admitted to a palliative care unit have a limited life expectancy. Sometimes, however, the accuracy of the prognosis is compromised by atypical progress of a disease or incorrect assumptions. If a predicted short life expectancy proves to be longer, the increased need of care may result in chronic admission and in a significantly reduced quality of life. A given poor prognosis may be mistakenly adhered to and might lead to insufficient diagnostic procedures or treatment. However, palliative care requires a patient-oriented and active approach. To be aware of possible incomplete diagnostics is an important step in preventing adverse consequences of a wrong prognosis.

Outcome measures for holistic, complex interventions within the palliative care setting.

Outcome measures for holistic, complex interventions within the palliative care setting.

Complementary therapies in clinical practice, Feb 2008 (epub: 26 Nov 2007), vol. 14, no. 1, p. 25-32
Thompson-Elizabeth-Anita, Quinn-Tina, Paterson-Charlotte, Cooke- Helen, McQuigan-Deidre, Butters-Graeme.
Author affiliation
Bristol Homeopathic Hospital Department, United Bristol Healthcare Trust, Palliative Medicine Bristol University, Cotham Hill, Bristol, UK. Elizabeth.thompson@ubht.swest.nhs.uk.
Abstract
As members of the Association of Palliative Care CAM (complementary and alternative medicine) Task Group we set ourselves two tasks: the task of exploring different facets of holistic care relevant to the palliative care setting and then to review outcome measures that might assist in researching complex interventions such as complementary therapies. Complementary therapies often embrace holistic philosophy where mind and body are connected and the complexity of symptoms acknowledged. These holistic or complex interventions within the palliative care setting are important to research and research holistically. We therefore gathered together outcome measures in the areas of hope, spirituality, symptom control, self-concept, the therapeutic consultation and dignity which would assist in the design of clinical trials of complementary therapies in the palliative care setting.

Critical literature review exploring the challenges of delivering palliative care to older people with dementia

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia
Deborah Birch BSc (Hons), RGN and Jan Draper BSc (Hons), PhD, RGN
Journal of Clinical Nursing Vol 17 No. 9 May 2008
pages 1144–1163

BMJ Learning modules

Here are the most popular modules in cancer for you to complete. The module on palliative care in the community has been among the most popular in the past 6 months.
Palliative care in the community "Very comprehensive overview of common problems encountered in practice"
Patients with recurrences of cancer: a guide to diagnosis and management
Managing the impact of a diagnosis of cancer
Side effects of chemotherapy: a practical guide for primary care
Athens username required

Effectiveness of Specialized Palliative Care : A Systematic Review

Effectiveness of Specialized Palliative Care : A Systematic Review
Camilla Zimmermann
JAMA 2008 ; VOL 299 ; PART 14 Journal Title:Access
JAMA - Journal of the American Medical Association
Page:1698 - 1709
CONTEXT: Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality. OBJECTIVE: To systematically review the evidence for effectiveness of specialized palliative care. DATA SOURCES: We performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: We included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost. DATA EXTRACTION: Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria. RESULTS: Of 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence. CONCLUSIONS: The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.

Multi-faceted palliative care intervention: aged care nurses’ and care assistants’ perceptions and experiences

Multi-faceted palliative care intervention: aged care nurses’ and care assistants’ perceptions and experiences
Jane L. Phillips, Patricia M. Davidson, Debra Jackson & Linda J. Kristjanson
Journal of Advanced Nursing Vol 62 No 2 April 2008
pages 216–227

Pediatric palliative care.

Pediatric palliative care.

Current oncology reports Nov 2007, vol. 9, no. 6, p. 437-9, 18 refs
Weidner-Norbert-J.
Abstract
Pediatric medicine is moving toward a greater appreciation that the delivery of quality medical care involves a partnership including the health care team, the child, and the family. Pediatric medicine now emphasizes the importance of information exchange among these groups. This paper discusses two models for communicating with children and their families throughout a complex life-threatening illness. Both models serve as a framework for integrating the medical and nonmedical aspects of the illness experience.
Publication type
Journal-Article, Review.

Journal of palliative care, Winter 2007, vol. 23, no. 4

Teaching interprofessional teamwork in palliative care--a values- based approach.
Full text available at ProQuest
p. 280-5, 45 refs

Pettifer-Annie, Cooper-Jan, Munday-Daniel.
Author affiliation
Faculty of Health and Life Sciences, Coventry University, Coventry, UK.
Publication type
Journal-Article, Review.

Practising interprofessional team--work from the first day of class: a model for an interprofessional palliative care course.
Full text available at ProQuest

p. 273-9, 23 refs

Cadell-Susan, Bosma-Harvey, Johnston-Meaghen, Porterfield-Pat et al
Publication type
Journal-Article, Review.

Sustainable practice improvements: impact of the Comprehensive Advanced Palliative Care Education (CAPCE) program.
Full text available at ProQuest
p. 262-72

Harris-Diane, Hillier-Loretta-M, Keat-Nancy.
Abstract
This paper describes an education program designed to improve palliative care practice through the development of workplace hospice palliative care resources (PCRs), and its impact on knowledge transfer and longer-term changes to clinical practice. Evaluation methods included pre- and post-program questionnaires, and a survey of learners' (n=301) perceptions of program learning strategies. Interviews (n=21) were conducted with a purposeful sample of PCRs and representatives from their work sites. Ratings of the sessions indicated that they were relevant to learners' clinical practice. At follow up, the majority of learners (83%) continued to serve as PCRs. Many positive effects were identified, including enhanced pain and symptom management, staff education, and development of care policies and guidelines. Management support, particularly the prioritization of palliative care and staff development, were factors facilitating sustained implementation. These findings highlight the importance of multimodal learning strategies and supportive work environments in the development of PCRs to enhance palliative care practice.

Nurse-physician collaboration in pain management for terminally ill cancer patients treated at home in Japan.
Full text available at ProQuest
p. 255-61
Ishikawa-Hirono, Kawagoe-Koh, Kashiwagi-Masayo, Yano-Eiji.
Abstract
Collaboration between nurses and physicians is essential for successful pain management, especially in home care settings. This study describes how physicians collaborate with nurses for the pain management of terminally ill cancer patients treated at home in Japan, and evaluates the use of standing orders in pain management. Self-administered questionnaires were sent to all 565 institutions listed in a nationwide database of home care service providers for terminally ill cancer patients; 177 responding institutions were analyzed. In general, institutions caring for fewer patients per year were less likely to make specific efforts to collaborate with nurses and less likely to use standing orders in pain management. Given that many institutions provide home palliative care services on a small scale, a standard protocol for care should be developed and applied across all institutions to ensure the availability of quality home palliative care throughout the country.

Meta-analysis of survival prediction with Palliative Performance Scale.
Full text available at ProQuest
p. 245-52; discussion 252-4

Downing-Michael, Lau-Francis, Lesperance-Mary, Karlson-Nicholas, Shaw-Jack et al
Abstract
This paper aims to reconcile the use of Palliative Performance Scale (PPSv2) for survival prediction in palliative care through an international collaborative study by five research groups. The study involves an individual patient data meta-analysis on 1,808 patients from four original datasets to reanalyze their survival patterns by age, gender, cancer status, and initial PPS score. Our findings reveal a strong association between PPS and survival across the four datasets. The Kaplan-Meier survival curves show each PPS level as distinct, with a strong ordering effect in which higher PPS levels are associated with increased length of survival. Using a stratified Cox proportional hazard model to adjust for study differences, we found females lived significantly longer than males, with a further decrease in hazard for females not diagnosed with cancer. Further work is needed to refine the reporting of survival times /probabilities and to improve prediction accuracy with the inclusion of other variables in the models.

Clinical nurse specialists in a Web-based practice environment.

Clinical nurse specialists in a Web-based practice environment.

The Canadian nurse, Jan 2008, vol. 104, no. 1, p. 19-23
Peters-Watral-Brenda, Stenekes-Simone, Wowchuk-Suzanne.
Abstract
The clinical nurse specialists working with the Canadian Virtual Hospice (CVH) are web-based, advanced practice palliative care nursing consultants. They deal with the complexities and challenges of online communication, particularly as it relates to the sharing of information about palliative and end-of-life care with lay people and health-care professionals alike. These nurses possess a number of highly developed skills--in communication, use of evidence-based research, teaching and understanding health-care systems--that enable them to respond to questions posed by visitors to the Ask A Professional section of the CVH website. Although the website is administratively based in Winnipeg, Manitoba, the services of the CNSs are available to people across Canada. In this article, the authors describe how the elements of advanced practice operate within this unique delivery model.

Use of the palliative outcome scale in Argentina: a cross-cultural adaptation and validation study.

Use of the palliative outcome scale in Argentina: a cross-cultural adaptation and validation study.

Journal of pain and symptom management, Feb 2008 (epub: 21 Dec 2007), vol. 35, no. 2, p. 188-202
Eisenchlas-Jorge-H, Harding-Richard et al
Abstract
Although measuring outcomes is essential to ensuring palliative care effectiveness, there is an absence of properly validated measures in many countries. We undertook a cross-cultural adaptation and validation of the Palliative Outcome Scale (POS) into a Spanish (Argentina) language and cultural context. The methodology used a sequence of phases: 1) verification of conceptual equivalence (literature review, professional interviews, and patient focus groups); 2) multiple translations; 3) committee review; and 4) field testing. Psychometric analysis entailed evaluation of quantitative content validity, construct validity, staff and patients' ratings comparison, internal consistency, test-retest reliability, and responsiveness to change. Conceptual equivalence was achieved. Multiple changes were introduced after the translations and field testing in 65 patients and 20 professionals. Content validity was high for all but one item. Construct validity against a validated quality-of-life measure (European Organization for Research and Treatment of Cancer Quality of Life C-30) was confirmed (rho=0.74, P<0.0005).>0.3) for 5/10, 8/10, and 6/9 items at each of three time-point evaluations and good correlation for all but one item (Spearman coefficient >0.7). Internal consistency was acceptable (Cronbach's alpha=0.68-0.69 and 0.66-0.73) for patient and staff ratings, respectively, and test-retest reliability showed very high agreement for every item (>0.80). The Argentine POS showed adequate responsiveness to change, although significant difference was reached for only 3 out of 10 items for patients and staff, respectively. Completion of the POS did not take more than 12 and 6 minutes for patients and staff, respectively. This study indicates that the Argentine POS is a valid and reliable measure of palliative care outcomes with advanced cancer patients.

A study of a training scheme for Macmillan nurses in Northern Ireland.

A study of a training scheme for Macmillan nurses in Northern Ireland.

Journal of clinical nursing, {J-Clin-Nurs}, Jan 2008, vol. 17, no. 2, p. 242-9
Gail-Johnston.
Macmillan Cancer Support, Macmillan Education Unit, Belfast, UK. Gjohnston@Macmillan.org.uk.
Abstract
AIM: To evaluate a one year training scheme for Macmillan Nurses. BACKGROUND: The role of the clinical nurse specialist has evolved and expanded greatly over the past few years so that it now encompasses components far beyond the traditional nursing remit of direct clinical practice. While several studies have looked at the barriers and facilitators to this process for clinical nurse specialists in particular, none has looked at the benefits of a structured training scheme which involves both a theoretical and clinical component. METHODS: Tape recorded, semi-structured interviews were undertaken with a purposive sample of trainees who undertook the scheme, their practice-based facilitators and another person(s) involved in the trainee's support. ANALYSIS: Tapes were transcribed verbatim and each transcript anonymized to prevent identification of participants. Data were analysed thematically using the main headings of expectations, experience and impact and the structured prompts from the aide-memoir within these headings. RESULTS: Results showed that the majority of respondents felt the scheme had been successful with one of the main achievements being that trainees were perceived to be adequately prepared to take on the role of a CNS on completion of the scheme. While the Role Development Programme was thought to provide a good academic structure for the scheme some participants thought that more theory on symptom control and communication skills and a placement in a specialist palliative care centre should also be included. CONCLUSION: The Macmillan Trainee Scheme has succeeded in its objectives to facilitate the transition from generalist to specialist nursing. It should be extended to include an induction and consolidation period and more theoretical input on communication skills and symptom control. RELEVANCE TO CLINICAL PRACTICE: With these improvements, the scheme could be used as a standard model for training specialist practitioners and a means to address the current issues of workforce planning.

Managing an acute pain crisis in a patient with advanced cancer: this is as much of a crisis as a code.

Managing an acute pain crisis in a patient with advanced cancer: this is as much of a crisis as a code.
Full text available at American Medical Association
JAMA : the journal of the American Medical Association, {JAMA}, 26 Mar 2008, vol. 299, no. 12, p. 1457-67
Moryl-Natalie, Coyle-Nessa, Foley-Kathleen-M.
Abstract
The assessment and management of an acute pain crisis in the setting of advanced illness is challenging. Using the case of Mr X, a 33- year-old man with advanced metastatic mucinous adenocarcinoma of the appendix and 15 out of 10 pain, we explore the issues of acute pain and its management. We define a pain crisis as an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family members, or both. Our management strategy focuses on making a pain diagnosis, differentiating reversible from intractable causes of pain, and making decisions about further workup; selecting the opioid and monitoring and treating opioid adverse effects; titrating and rotating opioid and coanalgesics; consulting experts to treat a pain crisis as quickly as possible to prevent unnecessary suffering; and co-opting the available institutional resources. The timely intervention of a palliative care team and its expertise can provide the staff, patients, and their families the benefit of an interdisciplinary approach and help the patients address goals of care; understand the benefits and risks of treatment decisions; and meet the psychological, social, and existential needs of the patient and the family commonly seen in this setting.

What health care providers know (and need to know) about palliative care.

What health care providers know (and need to know) about palliative care.

Full text available at ProQuest
Journal of allied health, {J-Allied-Health}, Winter 2007, vol. 36, no. 4, p. 209-15
Fox-Charles-R.
Abstract
Health care education has been widely criticized for not providing training in end-of-life care. Despite calls from various scientific and professional organizations for formal educational improvement, most education in this area is on the job. The current project is a secondary analysis of a surveyed convenience sample (n = 608) of health care providers in Kansas to determine knowledge, background, perceptions, and opinions about pain management and end-of-life care. The sample was primarily nurses (73%), with a small representation of other disciplines. The results of the survey indicate that providers believe they are ill prepared to provide palliative care and want professional education to improve knowledge and skills in this area. In addition, they state a need for increased support from insurers and legal and regulatory agencies to provide an acceptable standard of care. Providers responding to the survey also believe there is a significant need for patient education in this area.