Enhancing caregiver outcomes in palliative care.

BACKGROUND: Families are increasingly replacing skilled health care workers in the delivery of unfamiliar complex care to their relatives with cancer, despite other obligations and responsibilities that characterize their lives. METHODS: The authors review the needs of cancer caregivers and describe intervention strategies not only presented in the literature, but also implemented in their own program of research to address those needs during the palliative phase of cancer. RESULTS: Research suggests that developing interventions that teach caregivers to become proficient in the physical and psychological aspects of patient care will benefit both patients and caregivers. CONCLUSIONS: Despite the fact that a cancer diagnosis can cause major changes in family roles and functioning,as well as increased responsibility for complex care being absorbed by family caregivers, data supporting the effectiveness of caregiver interventions have been limited.

Cancer care: impact of interventions on caregiver outcomes.

The purpose of this review is to examine the research literature on interventions aimed at caregivers who, in the current health care environment, are assuming increasing responsibility for the complex care of significant others experiencing cancer. The general aim of the review is to synthesize the literature on interventions targeted to cancer caregivers and to summarize outcomes associated with the various intervention strategies described. Three broad categories of interventions were described in the literature: (1) educational, (2) counseling/psychotherapeutic, and (3) hospice and palliative home care. The review included studies that met the following criteria: data-based studies that described an intervention aimed at assisting caregivers to care for patients with cancer, studies published between 1975 and January 1999, and studies published in English. A total of 29 published papers was included. Although the original intent was to limit the review to studies that associated interventions with outcomes, a lack of well-delineated outcome variables was revealed as a major gap in the literature. Thus, some studies that did not include outcome variables were reviewed and the following conclusions made: (1) there is a dearth of data-based literature describing interventions aimed at caregivers; interventions that are described often lack well-defined effects due to a lack of or poor operationalization of outcomes; (2) of the small number of studies in this area, many used small samples and lacked randomization; and (3) studies often revealed selection bias to well-adjusted caregivers who were accepting of support, able to obtain respite care in order to participate, and often willing to avail themselves of a group-style intervention.

Participant characteristics before and 4 months after attendance at a family caregiver cancer education program.

Recent trends in health care have placed an increased burden on cancer caregivers. In response, nurses and social workers have been taught to implement a 6-hour psychoeducation program for cancer caregivers that addresses symptom management, psychosocial support, and resource identification. Longitudinal data from a convenience sample of 187 cancer caregivers who attended the program are reported. Data were collected before attendance and 4 months later. Findings confirm the chronic and consuming nature of cancer caregiving. Data indicate that perception of burden did not worsen even when caregiving tasks increased in intensity. Caregiver perceptions of their own health actually improved over time. In addition, the number of caregivers who said they were well informed and confident about caregiving after program attendance increased over time. Further study that randomizes caregivers to intervention/control groups is needed to substantiate the role of similar programs in enhancing caregiver skills and minimizing caregiver burden over time.

Role diversification in the education of advanced practice psychiatric nurses.

The mode, location, and focus of health care services are changing rapidly, especially delivery of psychiatric services. The high prevalence of psychiatric and medical comorbidity, the national shift in health care to a managed care arrangement with one professional designated as principle provider, and problems with access to comprehensive services for individuals with psychiatric problems interact to create a compelling need for a clear definition of advanced psychiatric-mental health nursing practice. This article is, in part, a response to the national dialogue and debate sparked by the beginning development of a psychiatric nurse practitioner certification exam. However, this debate will be used merely as a starting point to articulate and document the need for a flexible, diverse, and evolving definition of advanced psychiatric-mental health nursing practice that can inform and shape educational programs in the discipline.

Psychosocial issues associated with increased breast and ovarian cancer risk: findings from focus groups.

The advent of genetic testing for breast and ovarian cancer susceptibility has raised concurrent psychosocial issues. Within the context of limited health care resources, the ability to identify a subgroup of women who are at increased genetic risk for breast and ovarian cancers and who are also vulnerable to significant psychosocial sequelae is critical. Use of a focus group methodology substantiated the notion that there are factors that may predispose certain women who are at increased risk for developing breast and ovarian cancer to sustained psychosocial problems. In this era of rapid scientific strides coupled with efforts to contain health care costs, it is imperative that screening instruments be developed that can identify women who are at risk for significant psychosocial sequelae so that interventions can be instituted in a timely fashion.

Providing accurate information to women about tamoxifen therapy for breast cancer: current indications, effects, and controversies.

PURPOSE/OBJECTIVES: To address the uses of and current controversies surrounding tamoxifen therapy for the treatment and possible prevention of breast cancer so nurses may provide patients with accurate information. Factors that may hinder assimilation of information and strategies to enhance patient understanding are discussed. DATA SOURCES: Published, data-based articles and texts. DATA SYNTHESIS: The role of tamoxifen in controlling breast cancer includes adjuvant treatment for early stage breast cancer and palliative treatment of advanced disease. Investigational uses of tamoxifen include breast cancer prevention in women at high risk for the disease. Although tamoxifen has its proven benefits, confusion regarding who should take it still exists. CONCLUSIONS: Medical information as it relates to life-threatening disease often is transmitted to the public in an alarmist manner. While women still have legitimate concerns about tamoxifen use (e.g., increased risk of endometrial cancer and thromboembolic events), the benefits of this treatment for breast cancer (e.g., increased disease-free and overall survival, reduction in contralateral breast cancer) appear to far outweigh the risks. IMPLICATIONS FOR NURSING PRACTICE: Nurses should be cognizant of issues related to tamoxifen therapy so they can assist women in making informed decisions. Unbiased communication of the facts with attention to each woman's situation can facilitate individual consideration of options in an informed manner.

The development of a Family Caregiver Cancer Education Program.

BACKGROUND: Recent years have seen an escalating trend toward early discharge of hospital patients, resulting in increasing numbers of patients being cared for at home by family members. Fear and anxiety concerning the well-being of the patient, the inability to provide adequate care, the cost of cancer treatment, and the anticipation of emotional stress are major factors that can contribute to the difficulty of this transition. METHODS: The Family Caregivers Cancer Education Program has been funded by the Pennsylvania Department of Health, Cancer Control Program to address these issues. This program encompasses education and support for caregivers as well as the Local Instructor Course to provide nurse and social worker teams with materials, information, and support to offer the caregiver course within their areas. Focus groups were conducted to determine course content. RESULTS AND CONCLUSIONS: Participant evaluations demonstrate that caregivers who attend the course feel less overwhelmed and better able to cope with the caregiver experience.

Psychosocial aspects of palliative care.

OBJECTIVES: To provide information about factors that affect psychosocial adjustment among individuals and families who are faced with chronic illness; to discuss assessment guidelines and risk factors that may indicate a need for professional intervention; and to review psychosocial interventions that are used to minimized distress and promote adaptation. DATA SOURCES: Research studies, review articles, and book chapters. CONCLUSIONS: The majority of cancer patients experience emotional turmoil that occurs at transition points along the illness trajectory. Psychosocial issues faced by patients and their families are influenced by individual, sociocultural, medical, and family factors. IMPLICATIONS FOR NURSING PRACTICE: Supportive psychotherapeutic measures help to minimize distress, enhance feelings of control, and improve quality of life.

Depressive phenomena, physical symptom distress, and functional status among women with breast cancer.

The nature and scope of depression and its relationship to physical symptom distress and functional status were examined in 79 women 3 to 7 months after breast cancer diagnosis. Psychiatric diagnostic criteria for depressive disorders and a depression rating scale were used to measure depression. Nine percent of the sample had depressive disorder, and 24% had elevated depressive symptoms. Women with elevated depressive symptoms had more physical symptom distress (p < .0001) and more impaired functioning (p < .0001) than subjects with depressive disorders and without depression. Multiple regression was used to examine the contribution of key variables to functional status. Two variables accounted for 35% of the variance in functional status: symptom distress (28%) and depressive symptoms (7%).

Psychological distress and functional dependency in colorectal cancer patients.

This research was done to describe the nature and degree of psychological distress persons experience after receiving a diagnosis of colorectal cancer and to describe the effect on functional dependency of that distress during the first 3 months of treatment. The sample consisted of 66 persons who completed interviews before surgery and 1 and 3 months after surgery. Depressive symptoms changed substantially over time in relation to the events of diagnosis and treatment. Having an ostomy, additional treatment, and depressive symptoms were predictors of functional dependency after surgery. The findings suggest that depressive symptoms, even at low levels, are important to address because they may reduce patients' ability to function in their usual roles and activities for considerable periods after colorectal cancer surgery.

Development of a self-administered psychosocial cancer screening tool.

Among patients with cancer, psychosocial issues and problems are common, yet they often go unnoticed and thus untreated until they become severe and significantly interfere with the patient's comfort, quality of life, and potentially survival. Given the increasing complexity of cancer care, psychosocial support must assume a more prominent role in the care of individuals with cancer. Routine use of a screening tool for psychosocial assessment may help facilitate early identification and intervention for individuals who are at risk for psychosocial problems. Based on the prevalence of psychosocial problems described in the literature and the paucity of psychosocial screening instruments that can be applied practically in the clinical setting, the development of a new instrument to identify patients with cancer who have psychosocial problems in multiple domains and who thus are at risk for excessive psychosocial distress throughout the course of treatment is presented. This article provides background information, reviews the literature, including instruments that have been used to screen patients in the oncology setting for psychosocial problems, and presents a new instrument based on current deficiencies in this area. Pilot testing of the instrument demonstrates its feasibility for use in the clinical setting.

Nurses' reports of psychiatric complications in patients with cancer.

Increasing acuity of hospitalized patients with cancer has placed greater and more diverse demands on nurses. This is especially true in relation to the management of psychiatric problems that require added time and skills. This study surveyed all nurses (n = 100) working on 15 inpatient units in a 565-bed cancer research hospital on one day regarding psychiatric problems present in 475 patients under their care. Nurses reported that significantly more patients exhibited symptoms requiring psychiatric consultation than did not. Results also indicate that patients who were acutely ill and in need of intensive nursing care had significantly more psychiatric symptoms than patients with low acuity illness. The most prevalent symptoms were depression and/or anxiety and delirium. Nurses who must care for an increasingly ill population with more severe psychiatric symptoms need additional education to manage these problems. Study findings led to increased availability of nurse-to-nurse consultations as well as establishment of a task force to develop a psychosocial teaching manual.

Addressing the need for staff support among nurses caring for the AIDS population.

More and more nurses are caring for individuals with AIDS-spectrum disorders. When nurses become involved in hospital-based AIDS treatment, major psychosocial issues can arise. In settings where nursing personnel have limited or no experience working with patients with AIDS, fear of contagion is a major issue. This fear has both rational and irrational components. In general, providing up-to-date information in a small group setting can effectively reduce irrational fears. Rational fears, which are not as easily dealt with, should be a stimulus for behavior change (e.g., adoption of precautionary guidelines for reducing the possibility of accidental infection). Different issues arise among nurses specializing in AIDS care and include burnout, a sense of professional isolation, and the need to establish personal boundaries in dealing with patients. Guidelines are offered for establishing a group approach to address these concerns and to handle the sensitive issues that may arise.

Psychosomatic aspects of myocardial infarction and implications for treatment.

Psychosomatic intervention with patients who have suffered myocardial infarction is directed toward prevention of complications, development of realistic coping strategies, working through emotions, reduction of stress, and modification of coronary prone behavior.