Using undergraduate nursing students as mediators in a knowledge transfer programme for care for patients with advanced cancer.

Nursing today faces numerous challenges. Societal changes lead to reorganization of health care, changing workloads with sicker patients in hospital and home care, and limited economic resources. The increasing and changing nature of knowledge needed for expert care provision challenges nurses to continually update their competencies. These are issues demanding proactive and dynamic changes in the way nurses conceive their mandates and practice. The aim of the action-research project presented here was to foster improved quality of care for patients with advanced cancer through collaborative endeavours integrating cancer nursing clinical practice, research and education in a knowledge exchange programme. The programme was based on input about caregiving needs from multi-professional staff caring for patients with advanced cancer in a variety of healthcare settings. Undergraduate baccalaureate nursing students were then engaged in literature studies to help address these needs. Results of the studies were communicated back to the involved clinicians in a variety of ways. In this paper, we discuss what we have experienced as opportunities and obstacles in conducting the project, based on our reflections and external evaluations. This is linked to a broader discussion of ways of integrating cancer nursing research, education and practice.

Is good 'quality of life' possible at the end of life? An explorative study of the experiences of a group of cancer patients in two different care cultures.

The purpose of this paper was to explore how a group of gravely ill patients, cared for in different care cultures, assessed their quality of life during their last month of life. The study material comprised quality of life assessments from 47 cancer patients, completed during their last month of life. Two quality of life questionnaires, the EORTC QLQ-C30 and a psychosocial well-being questionnaire, were used. The data were treated in accordance with instructions for the respective questionnaires, and the results are presented primarily as means, mostly at the group level. Assessments from patients in two different care cultures, care-orientated and cure-orientated, were compared. The results show that despite having an assessed lower quality of life in many dimensions than people in general, several patients experienced happiness and satisfaction during their last month of life. 'Cognitive functioning' and 'emotional functioning' were the dimensions that differed least from those of the general population, and 'physical functioning', 'role functioning' and 'global health status/quality of life' differed the most. 'Fatigue' showed the highest mean for the symptom scales/items. There was a tendency for those cared for in the cure-orientated care culture to report more symptoms than those in the care-orientated care culture. An exception to this was 'pain', which was reported more often by those in the care-orientated care culture. The implications of the results are discussed from different angles. The significance of knowledge concerning how patients experience their quality of life is also discussed with respect to the care and the planning of care for dying patients.

Patient participation in decision making at the end of life as seen by a close relative.

The aim of the present study was to describe variations in patient participation in decisions about care planning during the final phase of life for a group of gravely ill patients, and how the different actors' manner of acting promotes or impedes patient participation. Thirty-seven qualitative research interviews were conducted with relatives of the patients. The patients' participation in the decisions could be categorized into four variations: self-determination, co-determination, delegation and nonparticipation. The manner in which patients, relatives and caregivers acted differed in the respective variations; this seemed either to promote or to impede the patients' opportunities of participating in the decision making. The possibility for participation seems to be context dependent and affected by many factors such as the dying patient's personality, the social network, the availability of different forms of care, cultural values, and the extent to which nurses and other caregivers of the different forms of care can and want to support the wishes of the patients and relatives in the decision-making process.

The last month of life: continuity, care site and place of death.

A hospice ward was opened in 1991 at the Orebro Medical Centre Hospital (OMCH) in Sweden. Shortly afterwards, a research project was started, which aimed to describe different aspects of the final period of life of a group of cancer patients. This exploratory study is part of this project and aims to assess continuity in the site of care for a group of severely ill cancer patients during the final stages of their lives, and their place of death within different cultures of care. This prospective study involved 56 adults with cancer who had been admitted to six specialized departments at OMCH. Demographic and diagnostic data, documentation of when the patients changed from one care form to another, as well as place of death were obtained. The analysis of continuity in terms of care site involved care-oriented cultures (hospice ward, hospital-based home care, primary care-based home care and nursing home) and cure-oriented cultures (acute hospital wards). Considered as a group, the patients spent one-third of their time at home during their final month of life, with or without formal caregivers. For individual patients, however, there were great variations with regard to continuity of care site and care form. A pattern was found for the type of cancer the patients had and where they were during their final month. Ten patients died in their own homes, and of the 46 who died in an institution, approximately the same number died in a care-oriented culture as in a cure-oriented culture.