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PubMed2003

Nutritional predictors of survival in terminally ill cancer patients.

BACKGROUND AND PURPOSE: Malnutrition can affect the prognosis of terminally ill patients, but over-treatment of malnutrition can worsen patients' quality of life. Decisions on nutrition and the supply of fluids to terminally ill patients are complex, and the identification of useful clinical indicators is needed. This study evaluated the relationships between various nutritional indices and survival of terminally ill cancer patients. METHODS: We recruited terminally ill patients from a teaching hospital between February 2000 and January 2001. All of the 145 candidates were cancer patients, 109 (75%) of whom agreed to participate. Nutritional assessments including physical examination, anthropometric measurements, and biochemical profiles were performed on admission. RESULTS: Univariate analyses showed that triceps skin-fold thickness (TSF) and midarm muscle circumference were significant predictors of survival. Poor survival was associated with prealbumin </= 100 mg/L (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.1 to 2.3; p = 0.03), asparate transaminase (AST) > 45 U/L (HR, 1.6; 95% CI, 1.1 to 2.3; p = 0.03), alkaline phosphatase > 120 U/L (HR, 1.6; 95% CI, 1.1 to 2.5; p = 0.02), creatinine > 1.4 mg/dL (HR, 1.9; 95% CI, 1.2 to 3.2; p = 0.01), and blood urea nitrogen (BUN) > 20 mg/dL (HR, 1.9; 95% CI, 1.3 to 2.8; p < 0.01) at admission. Multivariate analyses found that TSF < 25% of the nomogram (HR, 2.9; 95% CI, 1.6 to 5.3; p < 0.01), prealbumin </= 100 mg/L (HR, 2.2; 95% CI, 1.4 to 3.5; p < 0.01), AST > 45 U/L (HR, 2.0; 95% CI, 1.3 to 3.2; p = 0.01), and BUN > 20 mg/dL (HR, 2.8; 95% CI, 1.7 to 4.5; p < 0.01) were independent predictors of poor survival. CONCLUSIONS: This study found that nutritional status was associated with the survival of terminally ill cancer patients. Both TSF and prealbumin appeared to be useful predictors that may help set strategies to improve palliative care. Because predictors of survival are not necessarily factors that actually influence survival, further studies should be conducted to evaluate the usefulness of these prognostic indicators in clinical practice.

Adult↗
PubMed1976

Similarities in patient response to chronic and terminal illness.

Physical therapists sometimes hesitate to treat terminally ill patients because they believe the approach to them should differ from the approach to other patients. This belief is based on the assumption that patient needs during terminal illness differ from the needs of other patients. Some important similarities in patient reactions to chronic and terminal illness are explained. A conceptual framework of 'little deaths' is presented for comparing the two types of illness.

Adaptation, Psychological↗
PubMedDate not supplied

Palliative care of the terminally ill drug addict.

Palliative care with terminally ill drug addicts is a major challenge for medical professionals to face. With growing problems of prescription drug abuse in this country, the problem is only going to continue to grow and be faced more often. To date, very little has been done focusing on this special population of end-of-life care patients. This review article attempts to explore the terminology and definitions for identifying addiction in the terminally ill as well as exploring management options for healthcare professionals. As with other opioid treated pain patients, relying on terms such as "physiological dependence" and "tolerance" is inappropriate for use in this population, who are likely to have been on opioids for extended periods of time requiring dose escalation for progressive disease. Thus, these terms have little utility for identifying problem patients. Rather, understanding the context of the drug abuse as it reflects on the concepts of use despite harm and the damage inflicted to the physical, psychological, or social make-up of the patient is necessary. Recommendations include careful monitoring and assessment of patients, utilizing multidisciplinary team approaches, encouraging participation in recovery programs, and utilization of pill counts and urine toxicology screenings as necessary. Implications for the field are discussed.

Adult↗
PubMed1981

Impediments to communication in transition to terminal illness.

Viewing themselves in two hypothetical roles-as terminal patients and as family members related to a terminal patient-48 adults were surveyed on their expectations and preferences about how information should be communicated when a terminal illness is first diagnosed. Identifying with the patient role, respondents believed patients should be told the truth immediately and unconditionally. In contrast, respondents indentifying with family members perceived conditions under which the rights of patients should be abridged. In this latter role, male respondents were significantly less likely than males to imagine themselves as able to inform a loved one about a terminal illness. Nevertheless, for both sexes, early childhood experiences communicating about death and dying were found to be a better predictor of the case with which respondents can imagine communicating with a terminally ill loved one than are current adult attitudes and experiences. Regardless of personal ease in discussing death, however, most respondents thought the physician, not family members or other health care professionals, should decide when and how the terminally ill adult should be informed--a noteworthy finding in light of the fact that 83 percent of all respondents consider physicians poorly equipped for this role.

Attitude to Death↗
PubMedDate not supplied

The challenges of caring for families of the terminally ill: nurses' lived experience.

Caring for families of the terminally ill is an important aspect of nursing care as nurses are considered the main health care professionals who are closest to families. This paper describes the experience of seven registered nurses caring for families of the terminally ill in Western Australia. Five of the nurses worked in an acute area at a public hospital; the other two nurses worked at long-term care settings at a private hospital. Descriptive phenomenology as described by Husserl (1970) was used to describe and explore nurses' lived experience. Data were collected through in depth interviews and analysed using the Colaizzi method. Four major themes are reported in this paper: 1) walking a journey together; 2) dealing with intense emotions; 3) working as a team; and 4) balancing the dimension of care. Nurses' lived experiences of caring for families of terminally ill patients revealed that nurses are confronted by families' emotions and at the same time needed to manage their own emotions. The findings further indicated that nurses play a significant role in caring for families of the terminally ill. The family's fear of losing their loved ones often resulted in conflicts, which required extra time from nurses. Moreover, some of the major barriers identified were time constraints and excessive workloads. Finally, some implications of the findings for registered nurses are discussed.

Adaptation, Psychological↗
PubMed2003

When death is imminent: where terminally ill patients with cancer prefer to die and why.

End-of-life care strives to honor terminally ill patients' preferences regarding the way of dying. Scholars defined one domain of quality of dying and death as dying at the place of one's choice. Despite efforts over more than two decades and more than 40 studies to investigate the influencing factors associated with the place of death for terminally ill patients with cancer, there is a notable lack of empirical data examining the reasons why terminally ill patients with cancer choose a specific setting as their preferred place of death. An exploratory and descriptive study was conducted to explore the preferences of terminally ill patients with cancer for the place of death, to identify the reasons for selecting a preferred place of death, and to examine the importance of dying at a place one prefers. A convenience sample of 180 terminally ill patients with cancer was recruited from four tertiary care hospitals and two home care programs in Connecticut. Nearly 90% of the subjects preferred to die at home. Quality of life, availability and ability of family caregivers, concerns of being a burden to others, long-standing relationships with healthcare providers, and quality of healthcare were the major considerations in decision making regarding the place of death. Terminally ill patients with cancer acknowledged dying at their preferred place of death as highly important. Effective nursing interventions need developing to facilitate death at a place that is in accord with dying patients' preferences.

Attitude to Death↗
PubMed1993

Cultural awareness in the context of terminal illness.

While cultural awareness provides direction for planning effective nursing interventions at all stages of health and illness, this article specifically addresses applications for patients who are terminally ill. Professional nurses encounter unique challenges in caring for terminally ill patients. Assisting patients to achieve an "appropriate death" requires communication and collaboration among patients, family members, and professional caregivers. Since patients and their families represent many systems of complex beliefs and values, nurses must be aware of the impact of cultural pluralism on nursing assessment and intervention in terminal illness. Reordering priorities and redistributing resources have been identified as new approaches in caring for terminally ill patients and their families. Two concepts that cut across all cultural boundaries are loss and grief. Expressions of loss and grief take on a variety of forms among members of diverse cultures. It is critical that nurses recognize, understand, and respect each family's culture-specific patterns with regard to terminal illness. Understanding the culture will lead to the design of culturally appropriate nursing care for patients and families. Culture brokerage is defined as an act of translation, where messages, instructions, and belief systems are exchanged between cultural groups. This strategy has the potential to increase understanding among those with diverse cultural backgrounds, resulting in increased patient/family satisfaction within the supportive care setting. Consonance between patients' needs and nurses' understanding of those needs will lead to more culturally appropriate intervention strategies.

Attitude to Death↗
PubMed1997

Does it make clinical sense to equate terminally ill patients who require life-sustaining interventions with those who do not?

Two US courts of appeals have ruled that competent, terminally ill patients have a constitutional right to physician-assisted suicide. The cases are now before the US Supreme Court, which is expected to issue a ruling later this year. This article analyzes the keystone of the courts' ruling: their assertion that competent, terminally ill patients who are being kept alive on life support are equivalent to competent, terminally ill patients who do not require such support. Because the former are permitted to end their lives by refusing treatment, the courts found that the latter also have a right to determine the time and manner of their death, through prescriptions for lethal doses of medication. This article analyzes whether the courts' thinking is premised on a clinically plausible view of the care of terminally ill patients. Based on a discussion of common situations involving terminal illness, we argue that the courts' reasoning is deeply flawed. The article also analyzes how the implications of the courts' reasoning might undermine the care of terminally ill patients.

Humans↗
PubMed2000

Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers.

CONTEXT: Euthanasia and physician-assisted suicide (PAS) are highly controversial issues. While there are studies of seriously ill patients' interest in euthanasia and PAS, there are no data on the attitudes and desires of terminally ill patients regarding these issues. OBJECTIVE: To determine the attitudes of terminally ill patients toward euthanasia and PAS, whether they seriously were considering euthanasia and PAS for themselves, the stability of their desires, factors associated with their desires, and the proportion of patients who die from these interventions. DESIGN: Prospective cohort of terminally ill patients and their primary caregivers surveyed twice between March 1996 and July 1997. SETTING: Outpatient settings in 5 randomly selected metropolitan statistical areas and 1 rural county. PARTICIPANTS: A total of 988 patients identified by their physicians to be terminally ill with any disease except for human immunodeficiency virus infection (response rate, 87. 4%) and 893 patient-designated primary caregivers (response rate, 97. 6%). MAIN OUTCOME MEASURES: Support for euthanasia or PAS in standard scenarios; patient-expressed considerations and discussions of their desire for euthanasia or PAS; hoarding of drugs for suicide; patient death by euthanasia or PAS; and patient-reported sociodemographic factors and symptoms related to these outcomes. RESULTS: Of the 988 terminally ill patients, a total of 60.2% supported euthanasia or PAS in a hypothetical situation, but only 10. 6% reported seriously considering euthanasia or PAS for themselves. Factors associated with being less likely to consider euthanasia or PAS were feeling appreciated (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52-0.82), being aged 65 years or older (OR, 0.52; 95% CI, 0.34-0.82), and being African American (OR, 0.39; 95% CI, 0. 18-0.84). Factors associated with being more likely to consider euthanasia or PAS were depressive symptoms (OR, 1.25; 95% CI, 1.05-1. 49), substantial caregiving needs (OR, 1.09; 95% CI, 1.01-1.17), and pain (OR, 1.26; 95% CI, 1.02-1.56). At the follow-up interview, half of the terminally ill patients who had considered euthanasia or PAS for themselves changed their minds, while an almost equal number began considering these interventions. Patients with depressive symptoms (OR, 5.29; 95% CI, 1.21-23.2) and dyspnea (OR, 1.68; 95% CI, 1.26-2.22) were more likely to change their minds to consider euthanasia or PAS. According to the caregivers of the 256 decedents, 14 patients (5.6%) had discussed asking the physician for euthanasia or PAS and 6 (2.5%) had hoarded drugs. Ultimately, of the 256 decedents, 1 (0.4%) died by euthanasia or PAS, 1 unsuccessfully attempted suicide, and 1 repeatedly requested for her life to be ended but the family and physicians refused. CONCLUSIONS: In this survey, a small proportion of terminally ill patients seriously considered euthanasia or PAS for themselves. Over a few months, half the patients changed their minds. Patients with depressive symptoms were more likely to change their minds about desiring euthanasia or PAS. JAMA. 2000;284:2460-2468.

Adult↗
PubMed1990

Home care of the terminally ill.

General issues pertaining to the care of terminally ill patients in their homes are discussed. Lay home-care givers should be recruited as soon as the decision to care for a terminally ill patient at home has been made. Several home-care givers are usually needed for each patient, and the recruitment search should extend beyond the immediate family. Training of home-care givers and patients should be planned so that it fits schedules and covers all details, such as infusion device operation, documentation, and who to contact in case of changes in patient condition. In addition to training, care givers need psychosocial support. In the interdisciplinary approach to home care, pharmacists, nurses, physical and occupational therapists, social workers, and others all participate on a home-care team. Clinical staff members often shoulder much of the responsibility for assessing patient status, informing the physician, and coordinating changes in therapy. The home environment demands flexible policies and procedures and simple, concise methods of monitoring and documentation, especially when intractable pain is being managed. Because less control is possible in the home setting than in the hospital, it may be more difficult to comply with legal requirements concerning controlled substances. Final decisions about how home-care providers will be reimbursed are awaited. Practice standards for home care are being defined and recognized. Home care is a rational alternative for many terminally ill patients but raises new challenges.

Home Care Services↗
PubMed1988

The use of hospital beds for terminally ill cancer patients.

A study to identify reasons for admitting terminally ill cancer patients to hospital is reported together with recommendations for the future. Forty per cent of patients were so seriously ill with pain, medical or nursing problems that their carers could not manage satisfactorily at home and hospitalisation was necessary and appropriate. In addition 27% of patients admitted had no family or carers to nurse them at home. In the remaining 33% of patients it may have been possible with planned admissions and better supportive communications to allow some patients to die at home. Analysis of the data would suggest that there are three principal reasons for continuing to provide hospital beds for the terminally ill cancer patient: 1. Special medical and nursing care. 2. To provide care for some patients with no family or friend carer support. 3. Teaching of management by senior staff. The unsatisfactory nature of terminally ill patients dying in the centre of acute wards together with inadequate facilities to interview relatives is noted. It is suggested that the provision of well planned hospital beds is more appropriate than providing remote hospice beds for the terminally ill cancer patient.

Hospitals↗
PubMed1987

Spirituality and well-being in terminally ill hospitalized adults.

Initial research into the significance of spirituality among terminally ill adults was extended. Two hypotheses were examined using three groups of 100 adults matched on age, gender, education, and religious background: a) Terminally ill hospitalized adults indicate a greater spiritual perspective than nonterminally ill hospitalized adults and healthy nonhospitalized adults. b) Spiritual perspective is positively related to well-being among terminally ill hospitalized adults. All 300 participants completed the Spiritual Perspective Scale, Index of Well-Being, and other information. Planned comparisons analysis results supported the first hypothesis; low but significant correlation lent support to the second hypothesis. Differences among groups on recent change in spiritual views also were examined; a significantly larger number of terminally ill adults indicated a change toward increased spirituality than did nonterminally ill or healthy adults.

Adult↗
PubMed2005

Spouse caregivers of terminally-ill cancer patients as cancer patients: a pilot study in a palliative care unit.

OBJECTIVE: It is known that families of terminally-ill cancer patients show levels of emotional and functional disruption and are called "second order patients," however, little is actually known about the health problems of family members, especially in terms of cancer. METHODS: This study reviewed the family histories of terminally-ill cancer patients in a palliative care unit and investigated cancer related health problems of the spouses of terminally-ill cancer patients. RESULTS: We investigated the past medical history of 125 spouses of terminally-ill cancer patients and found that five spouses had a past medical history of cancer. In these five spouses, the duration of illness, present status of treatment and physical condition were reviewed from the database. Of these five spouses, three patients continued to attend an outpatient clinic regularly for checkup and one patient was hospitalized for nephrectomy. Two spouses did not have physical symptoms that made them unable to provide direct care for the terminally-ill spouses, while three could not provide care because of their own physical symptoms derived from cancer. SIGNIFICANCE OF RESULTS: Our findings indicated that some of the spouses of terminally-ill cancer patients are not only "second order patients" but also "cancer patients." Our findings also suggest that some spouses of terminally-ill cancer patients might experience distress both as a cancer patient and as a spouse and may need care both as a cancer patient and as a spouse.

Aged↗
PubMed1998

Perceptions related to time in a qualitative study of informal carers of terminally ill cancer patients.

Caring for a terminally ill relative is a complex, time-consuming experience. Demands on carers' time stem from a variety of sources, notably the practical and emotional work they must perform. Carers should be helped to plan their time effectively. Carers need to come to terms with their perceptions about past, present and future. Achieving some sense of equilibrium in the caring role is important. Professionals working with families experiencing terminal illness have a duty to assess each family individually in order to provide appropriate help and support.

Adaptation, Psychological↗
PubMedDate not supplied

Purposful dehydration in a terminally ill cancer patient.

The management of terminally ill patients who are unable to maintain their own hydration, or who express a wish to discontinue artificial hydration, is a significant controversial topic among healthcare professionals, patients and families. Evidence-based research suggests a number of medical and nursing indications and contraindications for dehydration. The purpose of this article is to review the current research, consider the factors involved in decision-making and clarify the complex issues which have implications for nursing surrounding the management of dehydration in terminally ill patients. The article uses the case of a patient nursed by the author and is written as a reflective account of practice.

Aged↗
PubMed1986

Religiousness among terminally ill and healthy adults.

The purpose of this study was to compare terminally ill with healthy adults for differences in religiousness; sense of well-being also was explored. This study was based upon a conceptualization of dying as a developmental phase of life. It was hypothesized that terminally ill adults report greater religiousness than healthy adults. A terminally ill and a healthy group with 57 adults each were matched on four key variables: age, gender, education, and religious affiliation. All 114 participants completed two questionnaires: the Religious Perspective Scale and the Index of Well-Being. A t-test of differences between the group means supported the hypothesis (t (112) = 3.11, p less than .001). There was no difference between the groups on sense of well-being; both indicated moderately high levels of well-being. A positive relationship between religiousness and well-being was found in the healthy group (r = .43, p less than .001), but not in the terminally ill group.

Adult↗
PubMed2003

Factors associated with the wish to hasten death: a study of patients with terminal illness.

BACKGROUND: There is considerable debate regarding the clinical issues surrounding the wish to hasten death (WTHD) in the terminally ill. The clinical factors contributing to the WTHD need further investigation among the terminally ill in order to enhance understanding of the clinical assessment and treatment needs that underlie this problem. A more detailed understanding may assist with the development of appropriate therapeutic interventions. METHOD: A sample of terminally ill cancer patients (N = 256) recruited from an in-patient hospice unit, home palliative care service and a general hospital palliative care consulting service from Brisbane Australia between 1998-2001 completed a questionnaire assessing psychological (depression and anxiety), social (family relationship, social support, level of burden on others) and the impact of physical symptoms. The association between these factors and the WTHD was investigated. RESULTS: A high WTHD was reported by 14 % of patients. A discriminant function analysis revealed that the following variables were associated with a high WTHD (P < 0.001): higher levels of depressive symptoms, being admitted to an in-patient hospice setting, a greater perception of being a burden on others, lower family cohesion, lower levels of social support, higher levels of anxiety and greater impact of physical symptoms. CONCLUSIONS: Psychological and social factors are related to a WTHD among terminally ill cancer patients. Greater attention needs to be paid to the assessment of psychological and social issues in order to provide appropriate therapeutic interventions for terminally ill patients.

Adult↗