Detecting and managing depressed patients : palliative care nurses' self-efficacy and perceived barriers to care

Background: Depression is a highly prevalent yet under-recognized and under-treated psychiatric illness in patients receiving palliative care. Nurses are the front-line health care professionals in these settings and are well-positioned to detect depressive symptoms and initiate pathways to care. Previous research suggests, however, that nurses' confidence and skills in relation to this task are low, and there appear to be a number of barriers within these settings that may impede nurses' engagement in this process.

Methods: To further investigate these factors, a quantitative study was carried out with 69 palliative care nurses from three palliative care services in Australia.

Results: A number of issues were identified, including the need for further training in the signs and symptoms of depression, issues around discussing depression with patients and their family members, and difficulty differentiating depressive symptoms from grief.

Conclusion: These findings provide insight into specific areas in which palliative care nurses would benefit from further training to improve detection rates for depression in this vulnerable population.

Evaluation of a training program to assist care staff to better recognize and manage depression among palliative care patients and their families

This study was designed to evaluate the effectiveness of a training program to improve the knowledge, attitudes, and self-efficacy of palliative care staff and thus enable them to better detect and manage depression among palliative care patients and their families. Participants were 90 professional carers who completed a four-session training program. Knowledge, attitudes, self-efficacy, and barriers to working with depressed patients were assessed preintervention, post-intervention, and at a three-month follow-up. The results demonstrated that compared to the control group, the intervention group had improved in all of these areas. Improvements were maintained at the three-month follow-up in all areas except attitudes. The results of this study indicate the importance of training in managing depression among palliative care staff. Booster sessions will likely be needed to ensure that training program gains are maintained.

Barriers to the detection and management of depression by palliative care professional carers among their patients : perspectives from professional carers and patients' family members

Introduction: Clinical depression is highly prevalent yet underdetected and poorly managed within palliative care settings.

Objectives: This qualitative study explored the identification, monitoring, and management of symptoms of depression in patients receiving palliative care from 2 juxtaposed perspectives that are of care providers and care recipients' family members. Examining the barriers that restrict professional carers detecting and managing depression in their patients was a central focus of the study.

Methods: Focus groups were held with 18 professional carers, including 8 holding managerial positions, across 2 palliative care services, 1 regional and 1 metropolitan, which provided both inpatient and community-based care. Individual interviews were conducted with 10 family members of patients who had received or were receiving palliative care through these services.

Results: Thematic analysis of these data identified that both professional carers and family members perceived that depression is a wide-spread concern for patients receiving palliative care; however, numerous barriers were identified that affect professional carers’ ability to identify depression. These included knowledge and training deficits, low self-efficacy, prioritization of physical concerns and time constraints, patient/family characteristics, and system/process issues. These themes (and related subthemes) are discussed in this article.

Conclusions: Specialized training in depression is recommended for professional carers in order to improve their depression-related knowledge, detection skills, and self-efficacy. The ultimate goal of such training is to increase the rate of recognition of depression that in turn will lead to appropriate treatment for depressed patients.

Feasibility of conducting a palliative care randomized controlled trial in children with advanced cancer: assessment of the PediQUEST study

Pediatric palliative care randomized controlled trials (PPC-RCTs) are uncommon.

Establishment and preliminary outcomes of a palliative care research network

Objective: The difficulties in conducting palliative care research have been widely acknowledged. In order to generate the evidence needed to underpin palliative care provision, collaborative research is considered essential. Prior to formalizing the development of a research network for the state of Victoria, Australia, a preliminary study was undertaken to ascertain interest and recommendations for the design of such a collaboration. Method:: Three data-collection strategies were used: a cross-sectional questionnaire, interviews, and workshops. The questionnaire was completed by multidisciplinary palliative care specialists from across the state (n = 61); interviews were conducted with senior clinicians and academics (n = 21) followed by two stakeholder workshops (n = 29). The questionnaire was constructed specifically for this study, measuring involvement of and perceptions of palliative care research. Results:: Both the interview and the questionnaire data demonstrated strong support for a palliative care research network and aided in establishing a research agenda. The stakeholder workshops assisted with strategies for the formation of the Palliative Care Research Network Victoria (PCRNV) and guided the development of the mission and strategic plan. Significance of results:: The research and efforts to date to establish the PCRNV are encouraging and provide optimism for the evolution of palliative care research in Australia. The international implications are highlighted.

Restorative care for palliative patients: a retrospective clinical audit of outcomes for patients admitted to an inpatient palliative care unit

BACKGROUND: Restorative care in palliative care is a subset of rehabilitation that aims to improve quality of life through restoration or maintenance of physical functions. Outcomes for restorative care programmes delivered by palliative care units have not adequately been assessed. OBJECTIVES: The objectives are to examine the outcomes of a restorative care programme in an inpatient palliative care unit, including discharge destination, performance status changes and length of stay. METHODS: Retrospective clinical audit of consecutive patients admitted to Calvary Health Care Bethlehem in Melbourne, Australia, principally for restorative care from July 2010 to December 2011. RESULTS: 79 admissions met inclusion criteria. Mean age was 76.5 years (SD=11.14) and 43 (54%) were men. 75 (95%) patients had a malignant diagnosis; of these, the majority had lung cancer (24%). 16 patients (20%) were discharged home, 51 (65%) died and 12 (15%) were transferred. Of the patients discharged home, only 6 (38% of those discharged home) improved their performance status. Those discharged home had a significantly shorter length of stay (17 days compared to 39 days; p<0.05). Patients discharged home also had significantly better Australia-modified Karnofsky Performance Status (AKPS) and Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) scores on admission than others (both p<0.05). CONCLUSIONS: The majority of patients referred for restorative care died during admission, with only a minority discharged home. Patients discharged most commonly experienced maintenance and not improvement in performance status. A successful discharge home following restorative care was associated with a shorter length of stay. Implications and recommendations for successful restorative care will be discussed.

Retrospective clinical audit of outcomes for patients admitted to an inpatient palliative care unit for restorative care

Background Restorative care in palliative care is a subset of rehabilitation that aims to improve quality of life through restoration or maintenance of physical functions. Outcomes for restorative care programmes delivered by palliative care units have not adequately been assessed.

Objectives The objectives are to examine the outcomes of a restorative care programme in an inpatient palliative care unit, including discharge destination, performance status changes and length of stay.

Methods Retrospective clinical audit of consecutive patients admitted to Calvary Health Care Bethlehem in Melbourne, Australia, principally for restorative care from July 2010 to December 2011.

Results 79 admissions met inclusion criteria. Mean age was 76.5 years (SD=11.14) and 43 (54%) were men. 75 (95%) patients had a malignant diagnosis; of these, the majority had lung cancer (24%). 16 patients (20%) were discharged home, 51 (65%) died and 12 (15%) were transferred. Of the patients discharged home, only 6 (38% of those discharged home) improved their performance status. Those discharged home had a significantly shorter length of stay (17 days compared to 39 days; p<0.05). Patients discharged home also had significantly better Australia-modified Karnofsky Performance Status (AKPS) and Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) scores on admission than others (both p<0.05).

Conclusions The majority of patients referred for restorative care died during admission, with only a minority discharged home. Patients discharged most commonly experienced maintenance and not improvement in performance status. A successful discharge home following restorative care was associated with a shorter length of stay. Implications and recommendations for successful restorative care will be discussed.

The lived experience of volunteering in a palliative care biography service

OBJECTIVE: Many patients approaching death experience hopelessness, helplessness, and a depressed mood, and these factors can contribute to a difficult end-of-life (EoL) period. Biography services may assist patients in finding meaning and purpose at this time. The aim of our study was to investigate the lived experience of volunteers involved in a biography service in Melbourne, Australia, using a qualitative methodology. METHOD: The participants were 10 volunteers who had participated in a biography service within a private palliative care service. Each volunteer was interviewed separately using a study-specific semistructured interview guide. The transcripts of these interviews were then subjected to thematic analysis. RESULTS: Analysis yielded the following themes: motivations for volunteering; dealing with death, dying, and existential issues; psychosocial benefits of volunteering; and benefits and challenges of working with patients and their families. Our results indicated that volunteering gave the volunteers a deeper appreciation of existential issues, and helped them to be more appreciative of their own lives and gain a deeper awareness of the struggles other people experience. They also suggested that volunteers felt that their involvement contributed to their own personal development, and was personally rewarding. Furthermore, the results highlighted that volunteers found that encounters with family members were sometimes challenging. While some were appreciative, others imposed time limits, became overly reliant on the volunteers, and were sometimes offended, hurt, and angered by what was included in the final biography. SIGNIFICANCE OF RESULTS: It is hoped that the findings of the current study will provide direction for improvements in the biography services that will benefit patients, family members, and volunteers. In particular, our findings highlight the need to provide ongoing support for volunteers to assist them in handling the challenges of volunteering in a palliative care setting.

Evaluation of two instruments of perceived symptom intensity in palliative care patients in an outpatient clinic

AIMS AND OBJECTIVES: To evaluate the test-retest stability in assessments of perceived symptom intensity on the Edmonton Symptom Assessment System-revised and the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. The possible interchangeability between the instruments and the patients' experiences of completing the instruments were also studied. BACKGROUND: The two instruments assess the same symptoms, but the symptom intensity is assessed on 11-point numerical scales on the Edmonton Symptom Assessment System-revised and on four-point verbal descriptive scales on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative. Both instruments are commonly used; however, uncertainty exists about which instrument should be recommended and about the interchangeability of the instruments. DESIGN: This study used a test-retest design with inter-scale comparisons. METHODS: Data from 54 patients with cancer who were receiving palliative care in an oncology outpatient clinic were self-reported by the patients in the clinic, at home and when patients returned to the clinic. RESULTS: The assessments on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative verbal rating scales showed a higher level of test-retest stability than the assessments on the Edmonton Symptom Assessment System-revised numerical scoring scales, indicating higher reliability. The correspondence between the verbal categories and the numerical scores of symptom intensity were low because different verbal categories were used by patients who assessed the same numerical score. CONCLUSIONS: The test-retest stability in the assessments was higher on the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative and the results show that assessments on the two instruments could not be used interchangeably. Therefore, the symptom instrument chosen must be specified and unchanged within a patient to improve efficacy in clinical practice. RELEVANCE TO CLINICAL PRACTICE: The Edmonton Symptom Assessment System-revised or the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire Core 15 Palliative can be used for initial assessments of patients, but should not be compared or used interchangeably. It is vitally important to have individual follow-up for all patients who score an instrument.

Vulnerability at the end of life: Australian veterans requiring home-based palliative care

In Australia, veterans are a vulnerable group, because of ageing, and high rates of chronic or life-threatening illnesses and poor mental health .This retrospective pilot study explored the home-based palliative care needs of veterans as they face the end of their life, compared to non-veterans. Medical records of ten deceased veterans and ten non-veterans in a home-based palliative care service were analyzed both for demographic data, and qualitative content. Veterans had significantly more comorbidities and were older at death. Qualitative data indicated common concerns, including the role of families and practical aspects of care. Some differences were found between veterans and non-veterans in their end-of-life care requirements. More awareness of veterans’ status may assist in care more tailored to their specific needs.

Palliative care for the person with a serious mental illness: the need for a partnership approach to care in Australia

When a person with a co-morbid mental illness requires palliative care, a balance in expert mental health and palliative care is critical to a dignified ending. The patient with a co-morbid mental illness requiring end-of-life care in Australia is currently under-recognized, and urgent consideration of the specific needs of this often discriminated against and stigmatized population is essential to provide appropriate care. This discussion paper explores the issues that arise when palliative care is necessary for a person living and dying with a mental illness, in the context of the Australian health care system and end-of-life care. A case for collaborative interprofessional clinical partnerships exists between the patient, family carers, and palliative care and specialist mental health clinicians, so that optimal care can be facilitated for the person living with a chronic or severe mental illness at the end of life.