Discharge planning in an acute hospital.

To improve discharge planning on an acute medical ward, a nursing "team system" was initiated with clear delineation of responsibility for discharge planning. The head nurse supervised the nurses' actions and supported their communication with attending physicians. To assess the efficacy of this approach, chart reviews and interviews of 60 consecutive patients were performed before and after the implementation of the plan. A plan was labeled adequate if the following criteria were met: all treatable diagnoses were recognized; appropriate treatment regimens were instituted for each diagnosis; the patient's abilities were sufficient for him to function in the proposed environment; and plans were made for follow-up care. Patient knowledge was stated to be adequate if the patient was aware of his diagnosis, treatment regimen and plans for follow-up care. In addition, the patient was questioned concerning his satisfaction with the plans for further care. Seventy-five percent of the patients admitted to this ward required discharge planning. Of those requiring discharge planning, the plan was judged adequate in 55% prior to the program change and in 83% following that change. Eighty percent of the patients required some teaching during their hospital stay. Of these, by the time of discharge, knowledge was adequate in 53% prior to the program change and 51% subsequent to the change. Initially 68% of the patients were very satisfied with the discharge plans but this figure rose to 86% following the program change.     

The choice between hospital and home care for terminally ill children

This study explored the decision making process of physicians and parents in choosing between hospital and home care for children in the terminal phase of cancer. Data were gathered from hospital records of the children and from interviews with their parents. Discriminant function analysis of hospital record data suggested that the physician's influence over care and treatment choices remained the dominant influence into the terminal phase. Yet parents reported that they were most influenced by their child's and their own desires and beliefs about their ability to provide care. The possibility of a two-stage decision process is offered to explain this discrepancy.     

Status and cost analysis of antimicrobial treatment of terminally ill patients with hematological malignancy in an acute hospital

ObjectiveTerminally ill patients with hematological malignancy tend to be treated aggressively. We aimed to clarify the status and costs of antimicrobial treatment of patients dying with hematological malignancies.MethodsThis retrospective study was conducted in a Japanese acute hospital between September 2010 and August 2015. A total of 141 patients who stayed for 14 days or longer and died in the hospital were investigated.ResultsThe median patient age was 67 years (range, 22–93). Most patients were treated with antibacterial, antifungal, and antiviral agents (98%, 75%, and 27% of the patients, respectively) in the last 14 days of their lives. The frequency of antibiotics used in the last 7 days did not differ from that of the week before.The median cost of antimicrobials was 245,000 JPY (2227 USD), which reflected 16% of the total medical costs spent over the last 14 days. A subgroup analysis of the patients according to care policy (aggressive care policy (A) and palliative care policy (P), respectively) showed that the total medical cost in group P in the last 7 days decreased from that of the preceding week; however, the cost of antimicrobials did not lessen even in the last 7 days.ConclusionsMost patients dying with hematological malignancy were treated with a broad spectrum of antimicrobials. It appeared to be difficult to reduce, let alone discontinue antimicrobial treatment even in patients treated according to the palliative care policy. The optimal use of antibiotics for hematological patients in their end-of-life should be discussed.     

Effects of an expanding home care program for the terminally ill

This study was a quasi-experimental time series design to test the hypothesis that an expanded program of home care for the terminally ill would reduce hospital utilization and costs of care during the last month of life. The data base was derived by comparing cancer deaths in persons less than 65 years of age over a 7-year period from a regional tumor registry against Blue Cross enrollment and claims files, to form claims histories for the last 6 months of life for 1,874 decedents who had made at least one claim during this period. Forty-six percent (46%) of the decedents had used home-care services, and a subgroup of high-intensity users was identified from daily home care charges during the last month of life. As the home care program expanded to provide more intensive home-hospice services, a trend was observed of greater cost savings among home-care users than among nonusers. These savings among users were achieved by a reduction in hospital days, and by a reduction in the mean daily cost of hospitalization. Home-care users also showed significantly less variability in costs than nonusers.     

Determinants of hospice home care use among terminally ill cancer patients

BACKGROUND: Despite the widespread availability of hospice services for more than two decades in the United States, currently many terminally ill cancer patients who may benefit from hospice care do not receive it. PURPOSE: To identify determinants of the use of hospice home care services for terminally ill cancer patients during their final days of life. METHODS: Secondary analysis of data from 127 terminally ill cancer patients who participated in a prospective and exploratory study aimed at identifying determinants of congruence between the preferred and actual place of death. Multivariate logistic regression analysis was conducted to identify determinants of hospice home care use. RESULTS: Sixty-four (50.4%) out of the 127 participants had used hospice home care services before death. Important determinants of hospice home care use included: (a) longer length of survival (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.01-1.03); (b) perceived greater family ability to achieve preferred place of death (OR: 1.85; 95% CI: 1.30-2.62); (c) home as the realistic preferred place of death (OR: 5.58; 95% CI: 1.95-16.03); (d) being female (OR: 5.37; 95% CI: 1.81-15.95); (e) lower levels of functional dependency (OR: 0.94; 95% CI: 0.89-0.99); and (f) use of emergency care during the final days of life (OR: 4.03; 95% CI: 1.26-12.94). CONCLUSIONS: The results of this study identified several groups of terminally ill cancer patients who were at a disadvantage to use hospice home care, including those without sufficient family resources but who required intensive nursing care. Providing nursing care that enables family care-taking at home may facilitate hospice home care use for patients.     

Prospective study of home morphine infusion in 62 terminally ill patients

The project “Infusion Therapy at Home” studied the practice of parenteral infusion therapy at home. Among the treatment modalities was the administration of morphine infusions to terminally ill patients. With infusion of morphine, patients were pain-free on 73% of the treatment days. Quality of care, quality of life, and costs were acceptable.     

A randomized controlled trial of a hospital at home service for the terminally ill

This study evaluated the impact of a Cambridge hospital at home service (CHAH) on patients' quality of care, likelihood of remaining at home in their final 2 weeks of life and general practitioner (GP) visits. The design was a randomized controlled trial, comparing CHAH with standard care. The patient's district nurse, GP and informal carer were surveyed within 6 weeks of patient's death, and 225 district nurses, 194 GPs and 144 informal carers of 229 patients responded. There was no clear evidence that CHAH increased likelihood of remaining at home during the final 2 weeks of life. However, the service was associated with fewer GP out of hours visits. All respondent groups rated CHAH favourably compared to standard care but emphasized different aspects. District nurses rated CHAH as better than standard care in terms of adequacy of night care and support for the carer, GPs in terms of anxiety and depression, and informal carers in terms of control of pain and nausea. Thus whilst CHAH was not found to increase the likelihood of remaining at home, at appeared to be associated with better quality home care.     

Evaluation of the cost of home care for terminally ill cancer patients

 The aim of this work was to carry out a cost evaluation of the home care programme for terminally ill cancer patients run by the Istituto Oncologico Romagnolo (I.O.R.) in the areas of Forlì, Cesena, Ravenna and Rimini (Romagna, Italy). To determine effective home care direct costs, we first selected 1 week of care as an observation unit. We then proceeded to assess the medical and nursing care units together with the clinical protocols administered for each patient. The Karnofsky Performance Status (KPS) was also assessed weekly. In this way, we calculated care costs for each patient and for each week as the sum of medical costs, nursing costs, treatment costs and other costs. A consecutive series of 574 patients were involved in the study from 1 April 1994 to 31 March 1995. A total of 5164 patient-weeks of care was provided, with an average cost per week of 177.6 Ecu. This weekly cost increased in the last 100 days of life (week –15=179.5 Ecu; week –8=188.3 Ecu; week –2=221.0 Ecu;P<0.001). When single components were analysed in relation to total cost (treatment protocols, physician and nursing care) the increased global cost was found to be mainly attributable to the intensification in nursing care (21.8% of costs in week –15 vs 27.3% of costs in week –2). Examination of the relation between the cost of 1 week of care and KPS values clearly shows that healthcare costs increased as KPS decreased (from 152.2 Ecu with KPS ≥60 to 292.6 Ecu with KPS ≤20;P<0.001). Home care costs were also seen to vary with some clinical characteristics and symptoms present when patients entered the study: asthenia, anorexia, nausea/vomiting, bedsores. Given the good results of home care for cancer patients in terms of quality of life, this method of cost accounting for home-care providers can help to monitor the rising cost of assistance and confirm the cost effectiveness of this type of care.     

Pain control in the terminally ill child at home

The seriously ill or terminally ill child with cancer has received inadequate pain control in the past, partly due to physicians' and nurses' fears and misconceptions regarding the administration of effective pain medications to a child. Advances in assessment techniques in the infant and young child, as well as increasing use of pain assessment questionnaires and VAS in the older child, have mandated changes in administration of analgesia to children. It is the responsibility of the health-care team of provide adequate pain control to the ill child, using knowledgeable assessment and monitoring skills. The goal of therapy for the dying child is to maintain comfort and support the child and the family. Providing analgesia in the hospital or the home has proven safe and effective when administered either orally or parenterally, and comfort of the child is achieved.     

Pain management in terminally ill patients

Successful management of pain in terminally ill patients depends on the physician's temperament, skill, and available time. Proper selection and regularly scheduled administration of medications, judicious use of adjunctive agents, and coordination of other professional services are vital. Drs Silverman and Croker explain the skills necessary to control the pain of terminal cancer patients.     

Nurses' attitudes to terminally ill patients

BACKGROUND: The care of terminally ill patients is a challenge for nurses that has raised special interest in recent years. Several studies have shown a stereotyped negative attitude in nurses towards terminally ill patients. However, all have used methods with several limitations. AIM: The aim of the study presented in this paper was to identify the nurses' attitude to the terminally ill patient in Catalonia, Spain, and the relationship of this attitude to different socio-demographic data (type of centre, shift, years of experience, age and sex) by means of a new quantitative method based on the free word-association test. METHODS: One hundred and seventy-five nurses working in 18 hospitals and hospices in Catalonia, Spain were included in the study. Data were analysed by the Associative Semantic Field Differential method by means of the computer programme CONTEXT and a quantitative evaluation of the degree of attitudes positivity was obtained. RESULTS: The study revealed a general slight negative trend in attitudes towards the terminally ill patient. A more positive attitude was observed in older caregivers and in women. The positivity in attitude decreased from morning to night shift. No differences were observed between nurses working in hospitals and those working in hospices. CONCLUSIONS: We conclude that nursing attitudes can be analysed by methods such as that used in this study. Attempts can be made to modify this attitude in caregivers by means of training programmes and stimulating awareness of an adequate professional approach.     

Fostering hope in terminally ill patients

AIM: To investigate the meaning of hope, identify strategies that terminally ill patients use in maintaining and fostering hope during the final stage of life, explore changes in hope during the dying trajectory and investigate whether the results of a North American study by Herth (1990a), that explored the meaning of hope and identified strategies to promote it, could be replicated in England. METHOD: A total of 16 adults receiving palliative care took part in the study. Cross-sectional data were collected on all participants. Longitudinal data were collected on four of the 16 participants using methodological triangulation, which encompassed a background data form, the Herth Hope Index and a semi-structured interview (Herth 1990a). FINDINGS: Hope remained present regardless of nearness to death. Seven hope-fostering categories and three hope-hindering categories were identified based on interview responses. CONCLUSION: The study supported Herth's original study (Herth 1990a), and could serve as a guide to individual practitioners and the nursing team in developing an environment and interventions that foster hope in people receiving palliative care in any setting.     

Pain relief in terminally ill patients

A systematic approach to identifying the cause of pain and rational use of drug therapy are keys to providing pain relief to cancer patients. Aspirin, acetaminophen and nonsteroidal anti-inflammatory drugs are effective for mild to moderate pain, and they enhance the effectiveness of weak oral narcotics, such as codeine. For severe pain, morphine is the drug of choice. A variety of adjuvant drugs can be used to enhance the effect of narcotics and to treat specific side effects of the disease or of therapy. For the terminally ill patient, a peaceful death with dignity should always be possible.     

Anxiety in terminally ill cancer patients

Context

Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress.

Objectives

This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients.

Methods

Participants were 194 patients with terminal cancer. Approximately half (n = 103) were receiving inpatient care in a palliative care facility and half (n = 91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support.

Results

Moderately elevated anxiety symptoms were found in 18.6% of participants (n = 36) and 12.4% (n = 24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety.

Conclusion

Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer.