Nurse education program on meaninglessness in terminally ill cancer patients: a randomized controlled study of a novel two-day workshop.

BACKGROUND: Fostering patients' sense of meaning is an essential task for palliative care clinicians. Few studies have reported the effects on nurses of a short-term training program aimed at improving skills to relieve feelings of meaninglessness in terminally ill cancer patients. OBJECTIVE: The primary aim of this study was to determine the impact on nurses of a novel two-day education program focusing on care that addresses patients' feelings of meaninglessness. Measured were impacts on nurses' confidence, self-reported practice, attitudes toward caring for such patients, burnout, meaning of life, and knowledge. METHODS: This study was a randomized controlled trial using the waiting list control. Intervention consisted of a two-day interactive education program. A total of 76 nurses randomly allocated to two groups completed the study. Outcome measures included confidence scale; self-reported practice scale; scales of nursing attitudes toward caring for patients who experience feelings of meaningless (willingness to help, positive appraisal, helplessness, nurse-perceived value of being, and nurse-perceived value of patients' inner power); Maslach burnout scale, Functional Assessment of Chronic Illness Therapy-Spiritual, and knowledge scale. RESULTS: There were significant intervention effects in nurse-reported confidence and nurse-perceived value of patients' inner power. Nurse-reported helplessness showed marginally significant improvement after intervention (p=0.067). No significant intervention effects were observed in the self-reported practice scale; attitudes toward caring for patients (willingness to help, positive appraisal, and nurse-perceived value of being); burnout scale, meaning of life; and knowledge score. The percentages of nurses who evaluated this program as useful or very useful were 95% (understanding the conceptual framework) and 85% (helping to learn how to provide care for patients feeling meaninglessness in clinical practice). CONCLUSION: This short-term educational intervention had a significant beneficial effect on nurses' confidence and modest effects on attitudes.

How and why did a regional palliative care program lead to changes in a region? A qualitative analysis of the Japan OPTIM study.

CONTEXT: Improving palliative care is one of the major issues throughout the world. OBJECTIVES: The primary aim of this study was to explore how and why a regional palliative care program led to changes in a region. METHODS: As part of a nationwide mixed-methods study of a regional palliative care program, a qualitative study was performed with 101 health care professionals involved in the implementation of the program. In-depth interviews were done, focusing on perceived changes and the perceived reasons for the changes. We used thematic analyses. RESULTS: Seven themes were identified as follows: 1) improved communication and cooperation among regional health care professionals; 2) increased confidence in the system to care for cancer patients at home; 3) improved knowledge/skills, practice, and perception of palliative care; 4) contribution to self-growth; 5) wide variability in perceived changes in the knowledge and perception of patients, family members, and the general public; 6) wide variability in the perceived regionwide effects of the project; and 7) unresolved issues. Participants emphasized improved communication and cooperation among regional health care professionals and stated a variety of ways of how communication and cooperation influenced daily practice. The main reasons for changes included regionwide interdisciplinary conferences and informal interactions at a variety of meetings. CONCLUSION: This study advances understanding of how the regional palliative care program created a change in the region. The findings are useful for developing a conceptual framework and identifying key interventions to improve regional palliative care for clinicians, researchers, and policy makers.

Effects of a programme of interventions on regional comprehensive palliative care for patients with cancer: a mixed-methods study.

BACKGROUND: Improvement of palliative care is an important public health issue, but knowledge about how to deliver palliative care throughout a region remains inadequate. We used surveys and in-depth interviews to assess changes in the quality of palliative care after regional interventions and to gain insights for improvement of palliative care at a regional level. METHODS: In this mixed-methods study, a comprehensive programme of interventions for regional palliative care for patients with cancer was implemented from April 1, 2008, to March 31, 2011 in Tsuruoka, Kashiwa, Hamamatsu, and Nagasaki in Japan. Interventions included education, specialist support, and networking. We surveyed patients, bereaved family members, physicians, and nurses before and after the interventions were introduced. We also did qualitative interviews with health-care professionals after the interventions were introduced. Primary endpoints were numbers of home deaths, coverage of specialist services, and patient-reported and family-reported qualities of care. This trial is registered with UMIN Clinical Trial Registry, Japan (UMIN000001274). FINDINGS: 859 patients, 1110 bereaved family members, 911 physicians, and 2378 nurses provided analysable preintervention surveys; 857 patients, 1137 bereaved family members, 706 physicians, and 2236 nurses provided analysable postintervention surveys. Proportions of home deaths increased significantly, from 348 of 5147 (6.76%) before the intervention programme to 581 of 5546 (10.48%) after the intervention programme (p<0.0001). Furthermore, 194 of 221 (87.78%) family members of patients who died at home answered that these patients had wanted to die at home. The ratio of patients who received palliative care services to all patients who died of cancer increased significantly (from 0.31 to 0.50; p<0.0001). The patient-reported (effect size 0.14; adjusted p=0.0027) and family-reported (0.23; p<0.0001) qualities of care were significantly better after interventions than before interventions. Physician-reported and nurse-reported difficulties decreased significantly after the introduction of the interventions. Qualitative interviews showed improved communication and cooperation between health-care professionals because of greater opportunities for interactions at various levels. INTERPRETATION: A regional programme of interventions could improve the quality of palliative care. Improvement of communication between health-care professionals is key to improvement of services. FUNDING: Third Term Comprehensive Control Research for Cancer Health and Labor Sciences Research Grants of the Ministry of Health, Labour and Welfare of Japan.

[Outreach program of palliative care team].

The primary aim of this study is to clarify the participant-evaluated usefulness of an outreach program by a palliative care team. The palliative care team participated in a community conference and clinical activity in collaboration with a community home care clinic once a month during one year. The palliative care team reviewed 44 patients, and gave 113 recommendations for 141 problems identified. The problems included physical symptoms (63%, including pain in 26%), psychological/spiritual issues (18%), family problems (6.4%), and the coordination of location of death (6.4%). 71% of participants rated the outreach problem as very useful and 29% found it useful. Usefulness for advising symptom control and developing collaborative relationship was high during the study periods, and usefulness for advising psychological care/communication and coordination of location of death gradually increased. In conclusion, an outreach program by a palliative care team could be useful for health care professionals in a community home clinic, and could contribute to better outcomes for cancer patients at home.

Terminal delirium: families' experience.

BACKGROUND: Although delirium is a common complication in terminally ill cancer patients and can cause considerable distress to family members, little is known about the actual experience of family members. The primary aims of this study were thus to explore: (1) what the family members of terminally ill cancer patients with delirium actually experienced, (2) how they felt, (3) how they perceived delirium and (4) what support they desired from medical staff. METHODS: A single-center in-depth qualitative study on 20 bereaved family members of cancer patents who developed delirium during the last two weeks before death. Content analysis of transcribed text was performed. RESULTS: Families experienced various events including other than psychiatric symptoms, such as ;patients talked about events that actually occurred in the past', ;patients were distressed as they noticed that they were talking strangely,' ;patients talked about uncompleted life tasks', and ;patients expressed physiologic desires such as excretion and thirst'. Family emotions were positive, neutral, or negative (eg, distress, guilt, anxiety and worry, difficulty coping with delirium, helplessness, exhaustion and feeling a burden on others). Families perceived the delirium to have different meanings, including positive meanings (eg, relief from real suffering), a part of the dying process, and misunderstanding of the causes of delirium (effects of drugs, mental weakness and pain). Families recommended several support measures specifically for delirium, in addition to information and general support: ;respect the patients' subjective world', ;treating patients as the same person as before', ;facilitating preparations for the patients' death', and ;relieving family's physical and psychological burden'. CONCLUSIONS: From the results of this study, we generated a potentially useful care strategy for terminal delirium: respect the patients' subjective world, treat patients as the same persons as before, explore unmet physiological needs behind delirium symptoms, consider ambivalent emotions when using psychotropics, coordinate care to achieve meaningful communication according to changes in consciousness levels during the day, facilitate preparations for the patients' death, alleviate the feelings of being a burden on others, relieve family's physical and psychological burden and information support.

[Palliative care in Seirei Mikatahara General Hospital Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital].

This paper illustrates a brief review of the development process of the palliative care team at the Seirei Mikatahara General Hospital. Palliative care team has been first instituted in 2002, and currently providing general support for cancer patients receiving chemotherapy not only for terminally ill patients. In future, we would start a regional palliative care program, including community palliative care team, to provide appropriate palliative care for all cancer population.

Self-reported practice, confidence, and knowledge about palliative care of nurses in a Japanese Regional Cancer Center: longitudinal study after 1-year activity of palliative care team.

Knowledge and skill deficits about palliative care in medical professionals are among the most common barriers to quality palliative care. This study in a Japanese regional cancer center was conducted to clarify nurses' self-reported practices, confidence, and knowledge, and the changes in these parameters after the 1-year educational and clinical activity of a palliative care team. Questionnaires were distributed to 134 nurses before and after a palliative care team conducted 6-topic educational programs and clinical consultation activity throughout the year. The nurses were asked to report their practices, confidence, and knowledge about palliative care in 5 fields (pain, dyspnea, delirium, communication, and dying-phase). In some areas of palliative care, hospital nurses did not adhere to recommended practices, had knowledge deficits, and were not generally confident with palliative care practices. However, daily palliative care team activities, including educational programs and clinical consultation service, could improve their practice and knowledge levels.

Changes in medical and nursing care in cancer patients transferred from a palliative care team to a palliative care unit.

The primary aim of this study was to explore the changes in medical/nursing care in patients who transferred from a palliative care team (PCT) to a palliative care unit (PCU) in the same hospital, and to explore the reasons why new or modified interventions were required. This was a retrospective study of 50 consecutive patients who were transferred from PCT to PCU in a 750-bed general hospital. A trained nurse performed a chart review and recorded the changes in 1) medical/nursing care, 2) help with decision-making within 48 hours after PCU admission, and 3) documentation of family and psycho-existential care. Group discussions among PCT and PCU staff members explored the potential reasons for the changes. Five patients were excluded due to admission periods of shorter than 48 hours. The number of new/modified medical and nursing care interventions after PCU admission averaged 1.9 +/- 1.5 and 1.5 +/- 1.3 per patient, respectively. The most common medical treatments were: reduction in hydration volume, dose titration of opioids, change in opioid administration device, opioid rotation, and addition of NSAIDs and steroids. The most common nursing interventions were: allowing patient to take a bath, changing mattress, use of massage, and discontinuation of bronchial suctioning. In addition, PCU staff newly coordinated opportunities to discuss preferred end-of-life care with primary caregivers in 38% of the cases, family members other than primary caregivers in 16%, and patients in 6.7%. The chart documentation of family care and psycho-existential care increased considerably after PCU admission. The chief reasons for these changes were: under-recognition of the problems and unavailability of treatments (pharmacological treatments), no intention to intervene and recommendations not followed by primary physicians (rehydration therapy), no intention to intervene (nursing care), and no intention to intervene and under-recognition of the problems (help with decision-making). These data demonstrate that many patients under PCT consultation receive new or modified interventions after PCU admission. Potentially useful strategies to strengthen the PCT interventions are: modification of intervention structure to minimize under-recognition of symptoms and decision making problems (e.g., use of standardized assessment tools, regular conferences), changes in the health care system to allow unlicensed drugs, clinical studies to clarify the benefits of artificial hydration therapy, and greater efforts to intervene in the areas of nursing care, help with decision making, family care, and psycho-existential care.