Journal of Palliative Care

This study's aim was to determine the impact of medical technologies on patient comfort and survival time, through retrospective review of the clinical course, symptom profile, and illness trajectory in 102 consecutive patients (50 males and 52 females), and of diagnostic and therapeutic interventions delivered to them. The average age of males was 72.3 years and of females 73.1 years. Ninety-four patients were admitted for palliation of symptoms due to malignant disease and eight other patients for non-malignant diseases. The median survival time was 12 days. On admission, higher univariate hazard risks for survival were significantly associated with male gender, metastatic disease, and dyspnea. Higher adjusted Charlson comorbidity scores were associated with significantly decreased survival time, while de novo symptoms and diagnostic interventions were associated with lower univariate risk rates and increased survival times. Palliative therapeutic interventions were not significantly associated with increased patient survival. A multivariate analysis showed that pain, dyspnea, immobility, and adjusted Charlson comorbidity scores were independent risks for shorter patient survival times. Diagnostic interventions were significant for increased patient survival. No requests for euthanasia had been recorded, which may, in part, reflect the significant family support most of these patients had received.

Funding bodies and accreditation organizations now demand objective data from hospice evaluations, and quantitative measures assessing outcomes. This is despite the fact that the goals and outcomes of hospice practice are not reductionist and are not easily quantified. One alternative to this bureaucratic challenge that does not necessitate compromise to hospice ideology is to develop an assessment tool through qualitative research using phenomenological data on carers’ insights with regard to hospice practice. In this article, the findings from the qualitative research that preceded the development of the assessment tool provide an insight into the key issues that carers give priority in evaluating a hospice. These findings provide valuable baseline data for understanding aspects of hospice practice that are valued by carers. The information gathered is a significant affirmation of the success of the hospice ideology and highlights the need to protect this precious philosophy. In short, it is an important statement about the need to keep the hospice spirit alive in client satisfaction. The findings from the qualitative study for the questionnaire can be interpreted as an affirmation to hospice workers that their vision and beliefs are valued and appreciated by those they serve.

Historically, health and social care professionals have described their lack of competence and confidence in many aspects of palliative care, and have recognized the need for increased educational opportunities, where new skills can be acquired and existing knowledge consolidated. Redressing these omissions has led to the development and growth of educational programs. Many of these courses have been unidisciplinary, with concomitant limitations. The adoption of a generalist approach to education has been suggested, to facilitate greater collaboration among professions and to ensure better use of resources. Course participants have greeted multiprofessional programs with enthusiasm. However, evidence of their effectiveness and impact on the delivery of palliative care to patients and their carers, although positive, remains scant. As the phenomenon of demographic aging continues, the growth of multiprofessional educational opportunities will amplify the need to scrutinize their content more closely.

The meaning of dignity is commonly assumed but rarely examined in palliative care. Dying with dignity often forms the basis of clinical decision making at the end of life, but is constructed differently depending upon setting and context. A discourse analysis of patient and family case studies found that relationships and embodiment were important aspects of dignity that have been neglected in the literature, although these constructions of dignity matter to dying people and their families. An understanding of these constructions can assist clinicians in providing sensitive palliative care across a range of community and medical settings.

This pilot study looks at the clinical application of bispectral index (BIS) monitoring within the palliative care situation. Using this instrument, the level of awareness in 12 patients was tracked from the onset of unconsciousness until death, and the levels were then related to the patients’ clinical state and treatment. The results give a surprising insight into the nature of unconsciousness in dying patients and the effects of treatment. The monitor proved to be a simple, effective, and acceptable method of assessing awareness in palliative care patients. A few minor problems were encountered in adapting it to the palliative care situation, but most of these were overcome as we became more familiar with the instrument. The study suggests that BIS could contribute significantly to patient care and lead to a better understanding of the dying process.