Living with severe chronic obstructive pulmonary disease (COPD): perceptions of patients and their carers. An interpretative phenomenological analysis.

BACKGROUND: A study designed to explore the experiences of patients with severe chronic obstructive pulmonary disease (COPD) and their carers, particularly with regard to ongoing and palliative care needs. METHODS: The participants were nine men and one woman with severe COPD and the carers of eight of the men, in East Devon, UK. Semi-structured interviews were undertaken, transcribed and analysed using interpretative phenomenological analysis (IPA). RESULTS: The emergent themes were of losses, adaptation, relationships with health professionals and effect on carer. Losses reflected the loss of personal liberty and dignity and of previous expectations of the future. Adaptation included strategies to cope with the effects of the disease. Relationships related to both positive and negative aspects of contact with health professionals. There was appreciation for continuity of care and reassurance. The effect on the carer was evident particularly as they had to take on multiple roles. They also experienced some of the same losses as the patient and appeared enmeshed with the illness. CONCLUSIONS: This study confirmed the inexorable decline in activities of daily life and social isolation for patients with severe COPD. Adaptive strategies were common and some positive aspects were identified. Support from the primary health care team was appreciated. The strain on carers was very apparent. The concept of a more structured sharing of information and a surveillance role mediated by health care professionals known to the patient and carer would be a pragmatic approach to improving care.

Home or surgery based screening for chronic obstructive pulmonary disease (COPD)?

AIMS: To compare the effectiveness of opportunistic spirometric screening of patients attending a general practice surgery with screening on randomly selected home visits. METHOD: 100 patients aged 45+ attending the Honiton Surgery (surgery group) and 100 randomly selected patients visited at their homes (home group) were invited to perform spirometry and complete a symptom and medication questionnaire. Main outcome measures were successful completion of spirometry and questionnaire and an estimate of COPD prevalence. RESULTS: Surgery assessments were successful in 94/100 (95% C.I. 89% to 99%) cases. Eighteen percent of those visited at home refused the invitation to attend for spirometry; 33% (95% C.I. 24% to 42%) resulted in a successful assessment; there was no. reply when visiting 46% of cases and 3% of he visits were refused or terminated on the day.The mean age of the surgery group and home group was 63.7 years and 64.5 years respectively. The mean time per patient was 17 minutes in the surgery group and 1 hour 26 minutes in the home group.Twenty five (27%, 95% C.I. 18% to 36%) of those assessed in the surgery group and 10 (30%, 95% C.I. 14% to 46%) of the home group had an FEV1 < 80% predicted. Of these, 14/25 (56%) and 4/10 (40%) were current or ex-smokers. Of these, eight and three respectively had cough, wheeze or breathlessness, giving an overall COPD prevalence of 11/127 (9%, 95% C.I. 0% to 19%). Three of these eleven (27%) had mild disease, 7/11 (64%) moderate and 1/11 (9%) severe. The mean age of the patients with COPD was 70.8 years. Four of the eleven (36%) patients with COPD already had a diagnosis recorded in their records (3 COPD, 1 asthma). Analysis of surgery attendance (any health care professional) of all patients aged 45 and above, indicated that over a one year period 79.1% (95% C.I. 78.2% to 80.0%) and over a two year period 89% (95% c.i. 88.3% to 89.7%) of the total practice population attended on at least one occasion. CONCLUSION: Opportunistic spirometric assessment of patients routinely attending surgery results in a high uptake; over a period of two years around 84% of the target population could be assessed. Home visiting may be used for reaching those not routinely attending the surgery.

Palliative terminal cancer care in community hospitals and a hospice: a comparative study.

BACKGROUND: Despite palliative care being an accepted role of community hospitals, there is little quantitative evidence of the type of care provided. AIM: To obtain quantitative data comparing palliative cancer care provided in 12 community hospitals in 10 towns (approximately 350 medical beds) and in a consultant-led purpose-built hospice (12 beds). METHOD: Retrospective medical and nursing case note analysis over one year of cancer deaths in the former Exeter Health District. RESULTS: A total of 171 community hospital and 116 hospice casenotes were analysed. Hospice patients had significantly different reasons for admission compared with community hospital patients (P < 0.001), with pain and symptom control being more frequent and terminal nursing care less frequent reasons for admission to the hospice. Community hospital length of stay was significantly longer than hospice length of stay (P = 0.002; mean community hospital stay 16 days, mean hospice stay eight days). Symptoms on admission differed significantly. Drug prescribing on admission and at death and indications of active treatment of symptoms were broadly similar. Community hospital patients received more investigations than hospice patients, linked to the observation that around one in ten community hospital patients were admitted for investigation and active treatment. Community hospital medical notes were significantly less likely to meet minimum quality standards than were hospice notes (81/171 vs. 18/116; P < 0.001), with major deficiencies in the areas of examination, progress reporting, and absence of confirmation of death. CONCLUSIONS: This study confirms the role of community hospitals in palliative terminal cancer care. Differences in care between community hospitals and a hospice have been demonstrated that may reflect either different admission populations to each setting or differences in the way care was delivered.

Dying from cancer in community hospitals or a hospice: closest lay carers' perceptions.

BACKGROUND: Despite there being around 400 community hospitals in the United Kingdom, there is little published research on the quality of service provided by these hospitals. AIM: To compare the quality of terminal cancer care in community hospitals with a hospice as assessed by patients' closest lay carer (relative or friend). METHOD: Structured interview (or questionnaire based on the interview proforma) with closest lay carers of all patients dying over one year in 12 community hospitals in east Devon and a purpose-built hospice in the city of Exeter. RESULTS: A total of 292 cases (176 in community hospitals and 116 in a hospice) were identified, resulting in 238 carers being eligible for interview or questionnaire survey. Overall, 106 successful interviews and 55 questionnaires were completed, giving a response rate of 67.6%. Carers gave a near unanimous vote of excellence for the total care given by the hospice, while around 40% of carers of patients in community hospitals considered that improvements were possible. Community hospitals attracted more negative comments than hospices, with criticism being directed at problems of communication, lack of nursing staff, and lack of support in bereavement. Carers of hospice patients were significantly more likely to be present at the time of death than those of community hospital patients [45/70 (64%) vs. 31/89 (35%); chi 2 = 13.6, P < 0.001], an observation possibly because nursing staff in community hospitals are less experienced at dealing with terminally ill patients and such hospitals have fewer adequate facilities. CONCLUSIONS: Lay carers indicated great satisfaction with care given in the hospice and less satisfaction with care given in the community hospitals. However, the community hospitals are non-specialist units with far lower levels of trained staff. Improvements in terms of the communication skills of doctors and nurses, specific training for nurses in palliative care, and structured bereavement care could be made without necessarily increasing staffing numbers.

Validation of current practice and a near patient testing method for oral-anticoagulant control in general practice.

When oral anticoagulant control is monitored in general practice, venous blood samples are usually transported to a central laboratory for determination of international normalized ratio (INR). An alternative is near patient testing by a commercial method. In a rural general practice 27 km from a central haematology laboratory, whole blood samples were drawn from patients receiving oral anticoagulants and analysed by three methods: after centrifugation, plasma separated and frozen in liquid nitrogen, transported to the laboratory, thawed and immediately analysed (control); courier transport of citrated sample to the laboratory for analysis (routine); near patient testing of whole blood sample (NPT). Maximum temperature achieved and time to analysis for routine samples were recorded. 306 complete sets of data were obtained. Comparison between the routine method and the control method revealed acceptable agreement. On multiple regression analysis, maximum temperature achieved did not contribute to differences observed but time to analysis of over 5 hours did make a significant contribution. Comparison between the NPT method and control method showed acceptable agreement, with persistent under-recording by the NPT method. The routine method for INR determination was validated as robust and reproducible with the proviso that needle-to-analysis time should be kept below 5 hours. The NPT method was valid under conditions of normal general practice. Strict quality control of NPT methods is essential if performance is to be comparable with that of established methods.

Characteristics of referrals to an inpatient hospice and a survey of general practitioner perceptions of palliative care.

In order to determine symptoms, drug prescribing and physical problems of patients referred to an inpatient hospice, case notes from 130 consecutive first admissions (95 general practitioner (GP) referrals, 35 consultant referrals) were analysed. GP referrals were more likely to be constipated, require care and be discharged to home. Consultant referrals were more gravely ill, dependent and more likely to die in the hospice. On admission 76 (58%) patients were receiving opiates with co-prescription of opiate and laxative occurring in 41% (31/76) of the cases. The prescription of laxatives with the symptoms of constipation occurred in 62% (26/42) of the cases on admission. A telephone survey of 79 referring GPs revealed that 37% had attended neither a course nor a lecture relevant to palliative care in the past 3 years. GPs experienced difficulties frequently or always in: (a) managing pain (8/79); (b) managing other symptoms (25/79); (c) helping patients and relatives cope with their emotional distress (18/79); and (d) coping with their own emotional responses to death and dying (5/79). In conclusion, the differences demonstrated between the GP and consultant referrals have implications for purchasers. The high incidence of possible opiate-induced side-effects and the difficulties with symptom control expressed by some GPs indicate a continuing need for effective educational input.

Appropriate place of death for cancer patients: views of general practitioners and hospital doctors.

BACKGROUND: The majority of cancer patients in the United Kingdom die in a National Health Service hospital, a setting that is contrary to the wishes of those patients expressing a preference to die elsewhere, for example at home or in a hospice. AIM: A study was undertaken to determine clinicians' views of the appropriate place of death for cancer patients and to examine factors leading to patients being admitted to a hospital specialist services unit where they died. METHOD: A questionnaire was sent to all general practitioners and hospital doctors who had cared for cancer patients who had died between May 1991 and April 1992 in a single health district. The appropriateness of the place of death, whether the patient was terminally ill, reasons for hospital admission and effect on management had different resources been available were determined. RESULTS: A total of 1022 deaths attributable to cancer were recorded for patients registered with general practitioners in the study area. Questionnaires were returned by general practitioners for 951 of the deaths (93%); hospital doctors returned questionnaires for 216 out of 268 patients (81%) who had been admitted to hospital under the care of a consultant. For deaths which had occurred at home, in a community hospital, residential/nursing home or Marie Curie hospice, the place of death was considered appropriate by general practitioners in over 92% of cases. For deaths in the hospital specialist services unit the place of death was considered probably or definitely appropriate by general practitioners in 83% of the 212 cases, but not appropriate in 17% of cases (P < 0.001 compared with all other settings). Hospital doctors considered 27% of deaths in the unit inappropriate. Significantly fewer cases fulfilled the criteria for terminal illness (death expected and palliative treatment commenced) according to general practitioners among those dying in the specialist services unit compared with deaths elsewhere (P < 0.001). The most common main reasons for admission to the specialist services unit were for investigation, because of difficult symptom control (apart from pain) and for curative/active treatment. General practitioners reported that management of between a sixth and a quarter of patients admitted to the specialist services unit would have been affected by the availability of 24-hour home cover, community hospital beds and a city-based hospice. Among the group of patients fulfilling the study criteria for terminal illness, the effect of other services on patient management would have been considerably higher. CONCLUSION: A greater proportion of cases where patients died from cancer in settings other than a specialist services unit were considered appropriate by general practitioners compared with deaths in a specialist services unit. For a considerable minority of patients, death in a specialist services unit was not considered appropriate by the general practitioners or by the hospital doctors. Improvements in local hospice facilities, community hospitals and community support would mean that a substantial proportion of hospital admissions could be avoided and thus cancer patients could die in more appropriate settings.

The influence of general practitioner community hospitals on the place of death of cancer patients.

All deaths from cancer were identified from death certificates in the Exeter Health District for a period of one year. Place of death, age, cancer type and access to general practitioner community hospital beds and the domiciliary hospice service were recorded. There were 1022 deaths attributable to cancer (parts 1a, 1b or 1c of the death certificate) who were patients of general practitioners in the health district. The place of death for patients with access to community hospital beds were: home 173/590 (29%), community hospital 232/590 (39%), specialist services unit 102/590 (17%), nursing or residential home 32/590 (5%), Marie Curie hospice 51/590 (9%). For patients without access to community hospital beds the place of death was: home 177/427 (41%), specialist service unit 165/427 (39%), nursing or residential home 42/427 (10%), Marie Curie hospice 43/427 (10%). The presence of community hospital beds was associated with a significant reduction of deaths in the specialist service unit (p < 0.001) and with a smaller reduction in home deaths (p < 0.01). Access to the domiciliary hospice services in areas with community beds was not associated with any significant change in the place of death. General practitioners cared for 74% of cases at the time of death in areas with access to community hospital beds and for 51% of cases without such access, which was a significant difference (p < 0.001). It therefore appears that community hospitals play a major role in the terminal care of cancer patients and access to such beds is associated with a decrease in cancer deaths occurring in specialist services beds.

Knowledge and perceptions of a domiciliary hospice service among general practitioners and community nurses.

Within a single district health authority all the general practitioners and community registered general nurses were asked to complete a questionnaire regarding awareness and perceptions of a domiciliary hospice service. Responses were received from 127 doctors (71%) and 58 nurses (80%). Awareness of resources offered by the domiciliary hospice service was high, especially among the 102 respondents with access to the service. Eighty per cent or more of general practitioners and community nurses were satisfied with the amount of information received concerning changes in the patient's condition and who was involved in the care process. However, 33% of nurses agreed that it was difficult to know who had overall responsibility for the patient's care and 28% of nurses felt that their own contribution was under-rated. These findings were reinforced by a number of written statements submitted by the nurses. There was a desire expressed by both general practitioners and community nurses for more educational input from the domiciliary service. Overall, assistance from the service was welcomed and its special skills acknowledged. In the future planning of a comprehensive hospice service the differing needs expressed by doctors and nurses should be taken into account.

High-performance liquid chromatography of 25-hydroxyvitamin D2 and 25-hydroxyvitamin D3 in human plasma. Use of isotachysterols and a comparison with gas chromatography--mass spectrometry.

A high-performance liquid chromatographic (HPLC) method for estimating plasma 25-hydroxyvitamin D2 (25-OHD2) and 25-hydroxyvitamin D3 (25-OHD3) is described. The method involves plasma extraction, Lipidex 5000 chromatography and HPLC on straight-phase Zorbax-SIL, collecting the 25-OHD2 + 25-OHD3 fractions. These secosteroids are isomerised to their isotachysterol derivatives and re-run in the same HPLC system, monitoring at 290 nm. 3H-Labelled 25-OHD3 is used as an internal standard. The method was evaluated in terms of reproducibility, and recovery of added secosteroids was quantitative. Values obtained using this method were in close agreement with those values obtained on the same plasma sample using gas chromatography--mass spectrometry.

Defective cortisol binding globulin affinity in association with adrenal hyperfunction: a case report.

A patient with an apparent abnormality of cortisol binding globulin (CBG) is reported. Investigations showed that while the plasma CBG binding capacity (equivalent to the plasma CBG concentration) was normal, the binding affinity was reduced by a factor of four. The significance of this observation is discussed with regard to its possible role in the development of the adrenocortical hyperfunction also seen in this patient.

The estimation of vitamin D and some metabolites in human plasma by mass fragmentography.

A mass fragmentographic assay for vitamin D3, 25-hydroxyvitamin D3, 25-hydroxyvitamin D2 and 24,25-dihydroxyvitamin D3 is described. After extraction of plasma with methanol and dichloromethane, Lipidex 5000 chromatography was used to separate the plasma extract into three fractions (a vitamin D fraction, a 25-hydroxyvitamin D fraction and a 24,25-dihydroxyvitamin D fraction). Cholesterol was removed from the vitamin D fractio by thin-layer chromatography. :After addition of vitamin D2 to each fraction, isotachysterol trimethylsilyl ethers were formed. Recoveries prior to gas chromatography-mass spectrometry were assessed by the use of tritiated standards added to the plasma before extraction. Using this procedure, normal ranges were established (vitamin D3: 3--17.7, 25-hydroxyvitamin D3: 5.9--35.2, 25-hydroxyvitamin D2: 0.6---1.0 and 24,25-dihydroxyvitamin D3: 0.6--2.9 micrograms/l).