Integrated palliative care within a general hospital

 The goal of the project was to integrate essential elements of palliative care into the regular duties of an internal ward located in a general hospital serving a rural area. To achieve this goal, the medical and nursing staff was moderately expanded, which was made possible by a grant from the Deutsche Krebshilfe, and training and supervision were instituted. Patients with malignant diseases in advanced and terminal phases were enrolled in the project and evaluated using a specifically designed documentation system. On average, 8.5 (18%) of the 46 beds on the ward were occupied by patients being cared for as part of the project at any one time. Effective relief of pain, nausea and respiratory distress were documented. For those dying in the hospital, a single room and the presence of family members were possible in the majority of cases. A high impact on the team became apparent through an anonymous questionnaire given during supervision. The project shows that it is possible to integrate palliative care into the work of a regular internal medical ward, with positive consequences for the patients and the team. Published online: 9 September 1999     

Developing an educational programme in paediatric palliative care

Paediatric palliative care has increasingly been recognised as a specialist area of practice. Essentially it is a holistic approach to care that embraces a range of elements concerned with not only the management of symptoms but also the psychosocial and spiritual needs of the child and family through death and bereavement. Children requiring palliative care represent a diverse patient group whose illness trajectories are often prolonged and unpredictable and this creates much stress for children themselves, their families and professionals who support them (Price and McFarlane, 2006). Such an approach to care is unique and the development of paediatric palliative care educational programmes requires careful and thorough planning, with the specific needs of the child and family being pivotal to the process. This article recounts the development of the first paediatric palliative care programme in Ireland using the curricular cycle described by Peyton (1998).     

Corneal donation within palliative care: a review of the literature

Corneal donation occurs infrequently within palliative care, even though the majority of the public say they are in favour of donating organs and tissue after death. One of the roles of the health professional is to provide patients with the necessary information to make choices, and this should include the option of donating their corneas should they so wish. This literature review explores how the subject can be raised in a systematic manner within palliative care. It looks at the potential benefits and dangers of involving the patient in such discussions, and the effects on the families. Practical issues, such as when to raise the issue, are also considered. Finally, the review discusses the implications for nursing practice and research.     

Transdermal fentanyl for pain relief in a paediatric palliative care population

This multicentre, observational study examined the efficacy of the therapeutic transdermal fentanyl system (TTS-fentanyl) in children requiring opioids for pain in life-threatening disease. Forty-one children receiving oral morphine (median dose 60 mg/day) transferred to transdermal fentanyl (median dose 25 micrograms/h according with the manufacturer's dose conversion guidelines). Twenty-six children completed the 15-day treatment phase, seven died due to disease progression and eight were withdrawn because of adverse events, inadequate analgesia or a change to parenteral opioids. After 15 days, the median fentanyl dose was 75 micrograms/h (range 25-250). No serious adverse events were attributed to fentanyl. There was a trend toward improved side-effects and convenience with fentanyl. Twenty-three of 26 parents (three missing) and 25 of 26 investigators considered transdermal fentanyl to be better than previous treatment. For all records available (at 15 days or on withdrawal if earlier), 75% (27/36) reported that fentanyl treatment was 'good' or 'very good'. The findings suggest that transdermal fentanyl is both effective and acceptable for children and their families.     

A hope is not a promise: fostering hope within palliative care

In palliative care, where patients have to live with a degree of uncertainty as to the possible course their illness may take and the length of life they may expect, hope is a major issue. It has been said that individuals who know they are going to die soon, can be literally dying for hope. Ahmedzai (1994) points out that a major challenge for palliative care is to find ways of inspiring patients towards new directions for hope. This reflective article will explore the nature of hope and discuss the potential problems surrounding false and unrealistic hope, and will focus on how nurses may foster and support hope throughout life-threatening illness and during the palliative phase of life.     

Continuing bonds and grief: a prospective analysis

Using data of 56 bereaved individuals, this study examined associations of various manifestations of continuing bonds, assessed at 7-12 months post-loss, with concurrent and prospective (9 months later) symptoms of grief and depression. Among other things it was found that, independent of initial symptom levels, manifestations of continuing bonds differed in their associations with subsequent grief and depression. That is, continuing bonds through recovering memories was a strong predictor of grief but not depression, whereas continuing bonds through the use of the deceased's possessions was a weak predictor of both grief and depression. In part, these findings contradict earlier prospective findings.     

An evaluation of teamwork within a specialist palliative care unit

This small-scale 10-month study evaluated teamworking within a specialist palliative care team. The study aims were to: collect, analyse and summarize information on how team members perceive teamworking; compare team members' perceptions after a teambuilding workshop; and to evaluate the longer term effect of this training on the team. A group of practitioners from a local Marie Curie Cancer Care Centre was selected and included members from all available disciplines. A piloted questionnaire was used to obtain qualitative and quantitative input. The team as a whole scored themselves above average on almost all counts. Following the teambuilding workshop significant improvement was seen in areas such as role appreciation and communication but not all improvements were long lasting. A perception of understaffing was noted as being one of the largest negative influences on teamwork whereas the setting and maintaining of agreed team objectives and having sufficient education opportunity were positive influences. Although teambuilding sessions appear to have the potential to produce the desired benefits, they should not be initiated at a time when staff already feel anxiety over their workload.     

Pilot project of an intermediate palliative care unit within a registered care home

In the UK, increasing pressure on the acute sector has meant that intermediate care has become a pertinent issue within the healthcare community. This article reports on a 6-month pilot project to develop a 2-bedded intermediate unit within a registered care home. A total of 27 patients were admitted to the unit for respite and terminal care. The project was monitored through outcome data sheets and discussions with staff. Satisfaction questionnaires were also distributed to GPs and families. It was found that the unit appeared to offer a workable alternative to inpatient care for those patients cared for in the study. More rigorous evaluation is needed to better determine the views of patients and families and to discover whether the service is able to reduce admissions to the acute sector and avoid delayed transfers of care.     

The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution

In January 2006 the Centre Hospitalier Universitaire Vaudois (CHUV), a large university hospital in Lausanne, Switzerland, became the first hospital in Switzerland to allow assisted suicide (AS) in exceptional cases within its walls. However, euthanasia is illegal. This decision has posed several ethical and practical dilemmas for the hospital's palliative care consult service. To address these, the team embarked on a formal process of open dialogue amongst its members with the goal of identifying a collective response and position. This process involved meetings every 4 to 6 weeks over the course of 10 months. An iterative process unfolded. One of the principal dilemmas relates to finding a balance between the team's position against AS and the patient's autonomy and the institution's directive. Although all team members expressed opposition to AS, there were mixed opinions as to whether or not the team members should be present during the act if requested so by patients. Some thought this could be misinterpreted as complicity in the act and could send out mixed messages to the public and other health professionals about palliative care. Others felt that the team's commitment to nonabandonment obliged them to be present even if they did not provide the drug or give any advice or assistance. The implications of nonabandonment are explored, as are several other questions such as whether or not the teams are obliged to provide detailed information on AS when requested by patients.     

The Diana community nursing team and paediatric palliative care.

This article describes the work of the Diana community nursing teams, a new nurse-led service funded by the Department of Health (DoH) to commemorate the life and work of Diana, Princess of Wales. It identifies paediatric palliative care as an emerging specialty within children's nursing and discusses how children and young people with life-limiting/threatening conditions and their families may benefit from this new service. It is anticipated that the Diana teams will work with existing services such as children's hospitals, outreach services, children's hospices, social services and education and voluntary agencies. A key element of this service will be the ability of Diana team members to work across professional and organizational boundaries to provide a seamless care service and promote the concept of 'joined-up working' (Hyman, 1998). Education in this specialty, preferably multidisciplinary education, is needed so that healthcare professionals in this field can share knowledge, skills and research findings and deliver up-to-date care based on clinical effectiveness.