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1.
AH Choudhuri 《Indian Journal of Palliative Care》2012,18(1):6-11
Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support, antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD. 相似文献
2.
Susannah McLean Ulugbek Nurmatov Joseph LY Liu Claudia Pagliari Josip Car Aziz Sheikh 《The British journal of general practice》2012,62(604):e739-e749
Background
Chronic obstructive pulmonary disease (COPD) is common. Telehealthcare, involving personalised health care over a distance, is seen as having the potential to improve care for people with COPD.Aim
To systematically review the effectiveness of telehealthcare interventions in COPD to improve clinical and process outcomes.Design and setting
Cochrane Systematic Review of randomised controlled trials.Methods
The study involved searching the Cochrane Airways Group Register of Trials, which is derived from the Cochrane Central Register of Controlled Trials, MEDLINE®, embase™, and CINAHL®, as well as searching registers of ongoing and unpublished trials. Randomised controlled trials comparing a telehealthcare intervention with a control intervention in people with a clinical diagnosis of COPD were identified. The main outcomes of interest were quality of life and risk of emergency department visit, hospitalisation, and death. Two authors independently selected trials for inclusion and extracted data. Study quality was assessed using the Cochrane Collaboration’s risk of bias method. Meta-analysis was undertaken using fixed effect and/or random effects modelling.Results
Ten randomised controlled trials were included. Telehealthcare did not improve COPD quality of life: mean difference –6.57 (95% confidence interval [CI] = –13.62 to 0.48). However, there was a significant reduction in the odds ratios (ORs) of emergency department attendance (OR = 0.27; 95% CI = 0.11 to 0.66) and hospitalisation (OR = 0.46; 95% CI = 0.33 to 0.65). There was a non-significant change in the OR of death (OR = 1.05; 95% CI = 0.63 to 1.75).Conclusion
In COPD, telehealthcare interventions can significantly reduce the risk of emergency department attendance and hospitalisation, but has little effect on the risk of death. 相似文献3.
Kylie Hill Suzanna Mangovski-Alzamora Gordon Guyatt Pauline Bragaglia Itamar Tamari Roger Goldstein 《Patient education and counseling》2010,81(1):14-136
Objective
To examine the effect of brief disease-specific education delivered in primary care on objective measures of knowledge in individuals recently diagnosed with chronic obstructive pulmonary disease (COPD).Methods
A randomized control trial was undertaken during which an experimental group received 2 h of education delivered by a certified COPD educator and a control group received usual care. The Bristol COPD Knowledge Questionnaire (BCKQ) was self-administered at the time of randomization and approximately three months later.Results
Of the 93 individuals that completed the study, 50 (forced expiratory volume in 1 s [FEV1] = 60.0 ± 14.3% predicted; 22 males) and 43 (FEV1 = 58.2 ± 14.4% predicted; 20 males) participants were randomized to the experimental and control groups, respectively. The BCKQ increased from 27.6 ± 8.7 to 36.5 ± 7.7 points (p < 0.001) in the experimental group, which was greater than any seen in the control group (between-group difference 8.3, 95% confidence interval 5.5-11.2 points).Conclusion
As little as 2 h of education delivered in primary care was effective at increasing objective measures of disease-specific knowledge.Practice implications
A program of brief education delivered in the primary care setting, represents an important approach for many individuals with COPD who are unlikely to access pulmonary rehabilitation. 相似文献4.
Maciek Godycki-?wirko Malgorzata Koziarska-Rosciszewska Katarzyna Kosiek 《Archives of Medical Science》2010,6(2):208-213
Introduction
In Poland, the National Health Fund (NHF) has contracted preventative interventions in primary health care (PHC) delivered by family physicians, internists, paediatricians and other physicians. The aim of the study was determining whether there is a correlation between PHC physicians’ specialisation and the rate of interventions delivered for the prevention of cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD).Material and methods
A retrospective observational study of the NHF 2005 data related to the delivery of prevention programmes using Spearman''s rank correlation coefficient (rho).Results
Out of 133 PHC providers in Lodz, 25 participated in the cardiovascular disease (CVD) prevention programme, 22 in the chronic obstructive pulmonary disease (COPD) prevention programme at a basic level, and 20 at an extended level (with contract completion rates respectively of 55.2, 47.8 and 51.5%). When all three prevention programmes were analysed together, the correlation between the rate of preventative interventions by physicians with a particular specialisation and the contract completion rate was positive (rho > 0) only for family physicians.Conclusions
Participation of primary health care providers in preventative programmes and the rates of their delivery of interventions were low despite additional funding. The correlation between the proportion of physicians with a particular specialisation, involved in CVD and COPD prevention interventions delivery, and the rate of the programme accomplishment was the strongest for family physicians. 相似文献5.
Peter Fairbrother Hilary Pinnock Janet Hanley Lucy McCloughan Aziz Sheikh Claudia Pagliari Brian McKinstry 《Patient education and counseling》2013
Objective
To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).Methods
Semi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.Results
38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.Conclusion
Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.Practice implications
Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support. 相似文献6.
《Patient education and counseling》2014,94(3):403-410
ObjectiveTo explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).MethodsSemi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.Results38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.ConclusionTelemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.Practice implicationsPatients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support. 相似文献
7.
Kirsty Boyd Bruce Mason Marilyn Kendall Stephen Barclay David Chinn Keri Thomas Aziz Sheikh Scott A Murray 《The British journal of general practice》2010,60(581):e449-e458
Background
Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.Aim
To assess the feasibility of implementing advance care planning in UK primary care.Design of study
Mixed methods evaluation of a pilot educational intervention.Setting
Four general practices in south-east Scotland.Method
Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.Results
End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.Conclusion
A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes. 相似文献8.
Chronic obstructive pulmonary disease (COPD) exacts a heavy toll on society, yet its prevention, diagnosis and treatment receives
inadequate attention from both the medical community and from society at large. Guidelines released in 2001 from the Global
Initiative for Chronic Obstructive Lung Disease (GOLD) are aimed at redressing this inequity. In this review, we integrate
information from the GOLD guidelines with recent updates on the prevention, treatment and management as related specifically
to the most severe form of this disease. In order to help distinguish COPD from other disorders that may mimic or confound
its treatment, we place particular emphasis on the definition, underlying pathophysiology and diagnosis of COPD. In addition,
we discuss future directions in pharmacotherapy. 相似文献
9.
Bruce Mason Eleni Epiphaniou Veronica Nanton Anne Donaldson Cathy Shipman Barbara A Daveson Richard Harding Irene Higginson Dan Munday Stephen Barclay Kirsty Boyd Jeremy Dale Marilyn Kendall Allison Worth Scott A Murray 《The British journal of general practice》2013,63(613):e580-e588
Background
Coordination of care for individuals with advanced progressive conditions is frequently poor.Aim
To identify how care is coordinated in generalist settings for individuals with advanced progressive conditions in the last year of life.Design and setting
A mixed methods study of three UK generalist clinical settings producing three parallel case studies: an acute admissions unit in a regional hospital, a large general practice, and a respiratory outpatient service.Method
Ethnographic observations in each setting, followed by serial interviews of patients with advanced progressive conditions and their family carers in the community. A spectrum of clinicians and healthcare workers were also interviewed.Results
Ethnographic observations were conducted for 22 weeks. A total of 56 patients, 25 family carers and 17 clinicians yielded 198 interviews. Very few participants had been identified for a palliative approach. Rapid throughput of hospital patients and time pressures in primary care hindered identification of palliative care needs. Lack of care coordination was evident during emergency admissions and discharges. Patient, families, and professionals identified multiple problems relating to lack of information, communication, and collaboration at care transitions. Family carers or specialist nurses, where present, usually acted as the main care coordinators.Conclusion
Care is poorly coordinated in generalist settings for patients in the last year of life, although those with cancer have better coordinated care than other patients. A model to improve coordination of care for all individuals approaching the end of life must ensure that patients are identified in a timely way, so that they can be assessed and their care planned accordingly. 相似文献10.
OBJECTIVE: This essay identifies elderly cancer patients as a population that experiences cancer-related health disparities at the end-of-life. METHODS: While hospice and palliative care (PC) are care options for this population, it is argued that PC prior to hospice will yield numerous benefits for long-term end-of-life care. RESULTS: It is theorized that PC prior to hospice will be beneficial in meeting the family's needs in a timely and adequate manner, improving quality of life, increasing caregiver satisfaction and communication, possibly delay institutionalization of the patient, and may ultimately impact bereavement. CONCLUSION: Patients would be able to benefit from PC in an early stage of their disease, positively influencing older cancer patients and families. PRACTICE IMPLICATIONS: Long-term assessment of the impact of PC prior to hospice is proposed as a promising direction of future research. 相似文献
11.
Smyth LJ Starkey C Gordon FS Vestbo J Singh D 《Clinical and experimental immunology》2008,154(1):56-63
Increased lung CD8 cells and their expression of chemokine receptors CXCR3 and CCR5 have been previously reported in chronic obstructive pulmonary disease (COPD). Alterations of CD8-CCR3 and -CCR4 expression and their ligands in COPD patients have not been fully investigated. The objective of this study was to assess in COPD patients: (i) broncho-alveolar lavage (BAL) CD8 CCR3 and CCR4 expression in COPD patients; and (ii) airway levels of the CCR3 ligands, CCL11 and CCL5. Multi-parameter flow cytometric analysis was used to assess BAL CD3 and CD8-chemokine receptor expression in COPD patients, smokers and healthy non-smokers (HNS). CCL5 and CCL11 levels were measured in BAL, and from the supernatants of lung resection explant cultures. CD8-CCR3 and -CCR5 expression (means) were increased in COPD patients (22% and 46% respectively) and smokers (20% and 45%) compared with HNS (3% and 22%); P < 0.05 for all comparisons. CD3CXCR3 expression was raised in smokers and COPD while CD8CXCR3 and CD3 and CD8 CCR4 expression was similar between groups. CD8CCR5 expression correlated to smoking pack years (r = 0.42, P = 0.01). COPD explants released more CCL5 compared with smokers (P = 0.02), while there was low level CCL11 production. CD8CCR3 and CCR5 expression appear to be regulated by cigarette smoke exposure. We show that COPD lung tissue released more CCL5, suggesting a role for CCL5-CCR3 signalling in pulmonary CD8 recruitment in COPD. 相似文献
12.
13.
Estefania Aguirre Antonio Galiana Alejandro Mira Ramón Guardiola Laura Sánchez‐Guillén Eduardo Garcia‐Pachon Miguel Santibañez Gloria Royo Juan Carlos Rodríguez 《APMIS : acta pathologica, microbiologica, et immunologica Scandinavica》2015,123(5):427-432
To identify the bacterial diversity (microbiota) in expectorated sputum, a pyrosequencing method that investigates complex microbial communities of expectorated sputum was done in 19 stable chronic obstructive pulmonary disease patients (mean (SD) FEV1: 47 (18%) of predicted value). Using conventional culture, 3 phyla and 20 bacterial genera were identified, whereas the pyrosequencing approach detected 9 phyla and 43 genera (p < 0.001). In sputum the prevalent genera with pyrosequencing approach were Streptococcus, Actinomyces, Neisseria, Haemophilus, Rothia, Fusobacterium, Gemella, Granulicatella, Porphyromonas, Prevotella and Veillonella. Enterobacteriaceae, detected frequently in conventional culture, were not significantly detected with pyrosequencing methods. In addition, we found that important pathogens such as Haemophilus and Moraxella were detected more frequently with the new genetic procedures. The presence of Enterobacteriaceae is probably overestimated with conventional culture, whereas other difficult cultivable pathogens are underestimated. These studies open a new perspective for evaluating the role of bacterial colonization in chronic obstructive pulmonary disease pathogenesis and progression. 相似文献
14.
An integral assessment framework of health status in chronic obstructive pulmonary disease (COPD) 总被引:1,自引:0,他引:1
Jan H. Vercoulen Leonie Daudey Johan Molema Petra J. Vos Jeannette B. Peters Mariska Top Hans Folgering 《International journal of behavioral medicine》2008,15(4):263-279
Background: To date, many health status instruments exist, but the validity of these instruments is questionable. This is caused by
the fact that health status is poorly defined.Purpose: To develop a validated framework that improves conceptual insight into health status and its domains.Methods: Based on theoretical and clinical considerations, we defined the domains of health status into concrete sub-domains by formulating
conceptual models. Guided by these conceptual models, for each sub-domain, existing instruments were selected. We validated
the conceptual models in the data of 168 COPD patients. Using factor analysis, underlying concepts in the data were identified.Results: The resulting framework included physiological functioning, complaints, functional impairment, and quality of life. These
main domains were shown to be subdivided into 15 sub-domains.Conclusions: The present study shows that health status consists of conceptually distinct sub-domains. Integral assessment of health
status thus entails measuring all sub-domains. Existing instruments measure only few sub-domains. Integral assessment of health
status thus requires the combination of different instruments. The present framework of health status can help in composing
such a battery of instruments. Patient profiles obtained by the framework are essential in individualizing treatment.
The study was supported by grants from the Dutch Asthma Foundation, GlaxoSmithKline, and the Department of Medical Psychology
and Department of Pulmonary Diseases of Radboud University, Nijmegen Medical Center. We are indebted to Dr. F. van den Elshout
(pulmonologist, Rijnstate Hospital, Arnhem) and Dr. R. Bunnik (pulmonologist, Maas Hospital, Boxmeer) for their contribution
in the patient recruitment, and to the multidisciplinary Taskforce Assessment of the Department of Pulmonary Rehabilitation
Unit for their invaluable contributions to the development of the conceptual models. 相似文献
15.
Shamil Haroon Peymane Adab Carl Griffin Rachel Jordan 《The British journal of general practice》2013,63(606):e55-e62
Background
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.Aim
To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.Design and setting
Pilot randomised controlled trial in two general practices in the West Midlands, UK.Method
A total of 1634 ever-smokers aged 35–79 years with no history of COPD or asthma were randomised into either a ‘targeted’ or ‘opportunistic’ case-finding arm. Respiratory questionnaires were posted to patients in the ‘targeted’ arm and provided to patients in the ‘opportunistic’ arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.Results
Twenty-six per cent (212/815) in the ‘targeted’ and 13.6% (111/819) in the ‘opportunistic’ arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the ‘targeted’ and ‘opportunistic’ arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = –0.5% to 3.08%]). Over a 12-month period, the ‘opportunistic’ case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the ‘targeted’ and £242.20 in the ‘opportunistic’ arm.Conclusion
Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this. 相似文献16.
Gazi Gulbas Yuksel Kaplan Ozden Kamisli Hilal Ermis Suat Kamisli Cemal Ozcan 《Respiratory physiology & neurobiology》2013,189(1):112-116
Many studies have focused on the systemic effects of chronic obstructive pulmonary disease (COPD), but none has examined neuromuscular junction transmission (NMT). We evaluated NMT dysfunction using single-fiber electromyography (SFEMG) in patients with COPD. Twenty patients with COPD and 20 age-matched healthy controls were included in the study. All patients and controls underwent SFEMG. Abnormal NMT was found in seven of 20 patients (35%), but in none of the control subjects. The COPD patients were subgrouped according to the presence of hypoxemia. The patients with normoxemia were classified as Group 1, and the patients with hypoxemia were classified as Group 2. Abnormal NMT was found in six patients in Group 2 and in one in Group 1. While there was significant difference in terms of abnormal NMT between Group 2 and the controls, there was none between Group 1 and the controls. Our results show that NMT abnormalities can be present in hypoxemic patients with COPD. 相似文献
17.
Mario Galgani Immacolata Fabozzi Francesco Perna Dario Bruzzese Barbara Bellofiore Cecilia Calabrese Alessandro Vatrella Domenico Galati Giuseppe Matarese Alessandro Sanduzzi Marialuisa Bocchino 《Clinical immunology (Orlando, Fla.)》2010,137(1):102-110
Dendritic cells (DCs) play an unsettled role in chronic obstructive pulmonary disease (COPD) pathogenesis. Two main blood subsets, myeloid (m) and plasmacytoid (p) DCs, have been identified in humans. Phenotype and frequency of circulating DC subsets were assessed by multi-parametric flow cytometry in 28 COPD patients and 30 healthy controls (15 never smokers and 15 smokers). Proportion and absolute number of pDCs were significantly reduced in COPD patients in comparison with never smokers (p < 0.001 and p < 0.003) along with a marked increase of the mDC/pDC ratio (p < 0.001). Analysis of peripheral lymphocyte subsets showed that the naive/memory T cell ratio was significantly reduced in COPD patients in comparison with never smokers (p < 0.001). Similar perturbations in the distribution of DCs and T cells also occurred in control smokers. This study is the first report of an imbalance of blood DCs in COPD. Influence of smoking and clinical relevance of these findings are discussed. 相似文献
18.
Stephen Barclay Katherine Froggatt Clare Crang Elspeth Mathie Melanie Handley Steve Iliffe Jill Manthorpe Heather Gage Claire Goodman 《The British journal of general practice》2014,64(626):e576-e583
Background
Older people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes.Aim
To describe care home residents’ trajectories to death and care provision in their final weeks of life.Design and setting
Prospective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire.Method
Case note reviews and interviews with residents, care home staff, and healthcare professionals.Results
Twenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: ‘anticipated dying’ with an identifiable end-of-life care period and death in the care home (n = 9); ‘unexpected dying’ with death in the care home that was not anticipated and often sudden (n = 3); ‘uncertain dying’ with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and ‘unpredictable dying’ with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study.Conclusion
For some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events. 相似文献19.
Chronic obstructive pulmonary disease (COPD) could develop following long-term exposure of individuals to cigarette smoke, toxic gases, and particulate matter, resulting in airway flow limitation, pulmonary failure, multiple systemic effects, and, eventually, death. The disease is associated with pulmonary inflammation with its own specific characteristics, and could be exacerbated by multiple factors such as microbial infection. COPD is chronic and progressive in nature, and multiple pulmonary inflammatory cells are detected at different stages of the disease, with a possible network of interactions with parenchymal cells. The pathological changes in the lung of COPD patients are characterized by an excess of extracellular matrix deposition, yet, loss of extracellular matrix in alveoli, increased thickness of airway walls, mucus hypersecretions, and destruction of alveolar septae, resulting in narrowing of airway diameters, reduced functional lung parenchyma, and decreased elastic tethering forces to maintain airway patency. Multiple factors, such as inflammatory cytokines, proteolytic proteinases, and oxidative stress molecules are suspected to be responsible, each at some degree, for these structural changes leading to airway obstruction. Because not everyone exposed to cigarette smoke will develop the disease, it is reasonable to think that multiple risk factors are involved and that COPD could be developed along a variety of pathways. Our current understanding of pulmonary changes associated with COPD, its similarity and differences with asthma, the nature of inflammatory cells associated with the disease, and the capacity of different molecules to induce a variety of these structural alterations are discussed to advance a cellular and molecular look at the pathogenesis of COPD. 相似文献
20.
Catherine Walshe Chris Todd Ann-Louise Caress Carolyn Chew-Graham 《The British journal of general practice》2008,58(549):264-272
BACKGROUND: Policies emphasise the importance of collaborative working in community palliative care. Collaborations are generally formed through formal and informal referral processes, but little is known about what influences professionals' decisions to refer to such services. AIM: To explore the influences on referrals within general and specialist community palliative care services. DESIGN OF STUDY: Qualitative, multiple-case study. SETTING: Three primary care trusts in the north-west of England. METHOD: Multiple data collection methods were employed, including documentary analysis, observation of referral team meetings and interviews. This paper primarily reports data from interviews with 47 health professionals, including GPs, district nurses, and specialist palliative care professionals. RESULTS: Judgements -- positive and negative -- about aspects of fellow professionals' performances appeared to influence referral decisions and ongoing collaboration and care. Attributes upon which these judgements were based included professional responsiveness and communication, respect, working and workload management practices, perceived expertise, and notions of elite practice. The effects of such judgements on referral and healthcare practices were altered by professional "game playing" to achieve professionals' desired outcomes. CONCLUSION: Palliative care policies and protocols need to take account of these complex and subtle influences on referrals and collaboration. In particular, teamwork and partnership are encouraged within palliative care work, but critical judgements indicate that such partnerships may be difficult or fragile. It is likely that such judgemental attitudes and practices affect many aspects of primary care, not just palliative care. 相似文献