Symptom burden at the end of life: hospice providers' perceptions.

To describe symptom prevalence, frequency, and severity among hospice patients, from the perspective of hospice providers, a cross-sectional study was conducted among 16 hospices participating in the Population-based Palliative Care Research Network (PoPCRN). Hospice staff estimated symptom presence, frequency, and severity, using the Memorial Symptom Assessment Scale. Among the 348 patients (median age 78 years, 55% female, 55% cancer diagnosis), the most common symptoms noted by hospice staff were lack of energy (83%), pain (76%), lack of appetite (63%), drowsiness (61%), difficulty concentrating (60%), and sadness (51%). When present, lack of energy was rated by hospice providers as both frequent (75% "frequently" or "almost constantly") and severe (46% "severe" or "very severe"). Symptoms varied by care setting and by diagnosis. Hospice staff often lacked sufficient information to rate potentially important symptoms, such as problems with sexual interest or activity (63%), change in self image (30%), and worrying (26%). This study identifies a significant burden of unrelieved symptoms among hospice patients, suggesting a need for more widespread institution of symptom management strategies with proven effectiveness and additional investigation into treatment of common symptoms for which few effective treatment strategies are known.

Impact of shorter lengths of stay on status at discharge in bipolar mania.

UNLABELLED: This study assesses the impact of shortening the inpatient length of stay on status at discharge in patients with mania. METHODS: The authors performed a chart review on 131 patients with discharge diagnoses of bipolar disorder, current episode manic type, admitted to the private attending service at Colorado Psychiatric Hospital between 1985 and 1995. In 1990, a new program (the alternatives program) that provides a continuum of acute care services and shorter inpatient lengths of stay was instituted. Retrospectively assessed GAF, CGI, treatment outcome rating scores, and length of stay (LOS) were compared for the prealternatives (1985-1989), early alternatives (1990-1992), and recent alternatives (1993-1995) program treatment eras. A progressive decrease in inpatient LOS, duration of the acute care episodes, and total service utilization was seen across eras. Despite the more recent shortening in LOS, no significant differences were seen in GAF and treatment outcome rating scores at discharge. GAF and treatment outcome rating scores on hospital days 3 and 7, however, suggested that patients were improving more rapidly in the more recent eras. Inpatient LOS and duration of the acute care episodes have significantly decreased over the last 10 years, but patients appear no more ill at discharge. The authors postulate that changes in psychopharmacologic practice and the inpatient treatment model may have facilitated the more rapid clinical improvement seen in the more recent eras. The authors caution that we need prospective studies that include postdischarge follow-up to assess further the impact of shorter inpatient stays on the posthospital course of manic patients.