An educational package that supports laycarers to safely manage breakthrough subcutaneous injections for home-based palliative care patients: development and evaluation of a service quality improvement.

BACKGROUND: Palliative care services strive to support people to live and die well in their chosen environment, with optimal symptom control and a pattern of care supportive of laycarers. The likelihood of patients remaining at home often depends upon laycarers, who may be required to manage subcutaneous medications. AIM AND DESIGN: This study reports the development, trial and evaluation of a package that teaches laycarers to manage subcutaneous medications used for symptom control in home-based patients. The package was developed by palliative care stakeholders and comprises an educational session, delivered by nurses, and a range of demonstrative, audiovisual and written resources. SETTINGS/PARTICIPANTS: The package was trialled across 24 sites and was evaluated by 76 laycarers (pre- and post-use) and 53 nurses (at study completion). RESULTS: Outcomes of primary interest were perceived global usefulness of the package and rated relevance of components. Laycarers and nurses rated the usefulness and relevance of the package highly - all means were above 5 on a 7-point scale. Also, laycarers were invited to comment on the package, and three focus groups for 26 nurses explored post hoc issues following package implementation. CONCLUSIONS: In terms of the palliative patient's illness trajectory, consensus was that the time for package introduction depended upon each particular clinical situation and laycarer. Nursing opinion was divided concerning whether it is safe and appropriate for laycarers to manage subcutaneous injections. Nevertheless, this study demonstrates that the package supports laycarers to manage subcutaneous medications. This has important implications for families, services and health-care systems.

A residential aged care end-of-life care pathway (RAC EoLCP) for Australian aged care facilities.

The objective of this study was to develop, implement and evaluate an end-of-life (terminal) care pathway and associated infrastructure suitable for Australian residential aged care facilities that improves resident and health system outcomes. The residential aged care end-of-life care pathway was developed by a multidisciplinary collaboration of government and non-government professionals and incorporated best clinical management for dying residents to guide care and increase palliative care capacity of generalist staff. Implementation included identifying and up-skilling Link Nurses to champion the pathway, networking facilities with specialist palliative care services, delivering education to generalists and commencing a Palliative Care Medication Imprest System in each facility. The primary outcome measure for evaluation was transfer to hospital; secondary measures included staff perceived changes in quality of palliative care provided and family satisfaction with care. Results indicated that the pathway, delivered within a care framework that guides provision of palliative care, resulted in improved resident outcomes and decreased inappropriate transfers to acute care settings.

The role of persuasive arguments in changing affirmative action attitudes and expressed behavior in higher education.

The research reported in this article examined the conditions under which persuasive arguments are most effective in changing university students' attitudes and expressed behavior with respect to affirmative action (AA). The conceptual framework was a model that integrated the theory of reasoned action and the elaboration likelihood model of persuasion. Studies 1 and 2 established effective manipulations of positive?negative AA information, and peripheral?central routes of processing. Study 3 implemented these techniques, and a path analysis was carried out testing the differential effects of valence of information processed via different routes on AA evaluative beliefs, attitudes, intention, and expressed behavior. Results indicated that positive AA messages processed centrally (i.e., for meaning) resulted in significantly more positive evaluative beliefs. Modifications to the original model resulted in a final model with excellent fit to the data that supported the mediating role of intention in the AA attitude?behavior relationship, as predicted by the theory of reasoned action. The findings highlight potential benefits of interventions for improving support for AA policies, provided that positive information is processed at a central, evaluative level.

Lay caregivers' perspectives on injecting subcutaneous medications at home.

BACKGROUND: Most palliative care patients prefer to be cared for at home. While promoting quality of life for patients, this preference impacts on their caregivers. Lay caregivers in Australia can be required to deliver and adjust complex medication regimens.This study aimed to investigate caregivers' perceptions concerning the injection of subcutaneous medications. METHODS: Fourteen caregivers were interviewed on two occasions, once during the caregiving phase and two months after bereavement. RESULTS: In the first interview, caregivers expressed anxieties associated with their ability to undertake the task of administering injections, including fears of overdosing their family member. In the bereavement interview caregivers reflected they were pleased they had contributed to the symptom relief of a family member and that although they would not necessarily volunteer to inject family members again, they were generally empowered by the experience. It is important for health professionals to support lay caregivers to successfully achieve their extended caregiving role.

Relief of incident dyspnea in palliative cancer patients: a pilot, randomized, controlled trial comparing nebulized hydromorphone, systemic hydromorphone, and nebulized saline.

Acute episodic breathlessness in patients receiving palliative care is a distressing symptom with little evidence-base to inform management. This pilot, double-blind, controlled, crossover study compared the effects of nebulized hydromorphone, systemic hydromorphone and nebulized saline for the relief of episodic breathlessness in advanced cancer patients. On three occasions of acute breathlessness, patients randomly received either nebulized hydromorphone, a systemic breakthrough dose of hydromorphone or nebulized saline together with a blinding agent. Breathlessness was scored before and 10, 20, 30, and 60 minutes post-treatment completion using a 100 mm visual analog scale. Twenty patients completed the trial. Ratings did not differ significantly across pretest treatments. Change in ratings from pretest to 10 minutes after completion of nebulization (about 20 minutes after administration of systemic hydromorphone) indicated that each of the treatments resulted in statistically significant improvements in breathlessness, with no significant differences between treatments. Over time, breathlessness decreased significantly for all treatments, with no significant differences between treatments. Only nebulized hydromorphone produced a rapid improvement in breathlessness that reached a magnitude considered to be clinically important. Interpretation of these results is considered in relation to our definition of clinical significance, the dose of hydromorphone used and the possibility of a placebo effect. This study can serve to inform the design of future trials to investigate the management of incident breathlessness.

Randomised controlled trials of palliative care - a survey of the views of advanced cancer patients and their relatives.

PURPOSE: To determine if patients with advanced cancer are interested in participation in palliative care research, particularly RCTs, and the importance of demographic factors in decision making. It sought relatives' views towards supporting trial entry, and assessed if demographic factors can predict participation. METHODS: A questionnaire was developed through multiprofessional focus groups, patient and relative interviews and pilot studies. Consecutive patients known by the palliative care service to have advanced disease were approached. Relatives of consenting patients completed a parallel survey. K-means cluster analysis was used to differentiate between those willing and unwilling to participate. Multivariate logistic regression identified demographic factors predicting willingness. RESULTS: One hundred and one patients and 100 relatives were included. 92% of patients would participate in studies involving simple interventions, whereas only 26% would consider studies of complex interventions. A similar pattern was observed for relative support. Over 75% of participants expressed altruistic views. Concepts of 'randomisation', 'placebo-control' and 'blinding' deterred about one-half. Many were prepared to complete short questionnaires, accept extra medications, investigations, hospital visits or admissions within a trial context but the possibility of side-effects was a major deterrent. Patient age was the only significant predictor of willingness to participate, with older patients less likely to participate. CONCLUSION: Despite the likely absence of individual benefit, many patients appear willing to participate in palliative care research. Trial design and the possibility of side-effects proved very influential in their decision making. Clinical trials in palliative care are more likely to be successful if developed in accordance with the views of patients and their relatives.

The effect of dexamethasone on the longevity of syringe driver subcutaneous sites in palliative care patients.

OBJECTIVE: To assess the effect of adding 1 mg dexamethasone to syringe drivers on the viability time of subcutaneous cannulation sites in palliative care patients. DESIGN: Prospective, double-blind, randomised, controlled trial in which patients received half their daily infused medications plus 1 mg dexamethasone in 1 mL saline through one subcutaneous site (test site) and the other half of their medications plus 1 mL saline through another symmetrically placed site (control site). PARTICIPANTS AND SETTING: Palliative care patients from the inpatient units at two hospices, recruited between 1999 and 2002. MAIN OUTCOME MEASURE: Difference in time that the test and control sites remained viable. RESULTS: 38 patients consented and were randomised. Twenty did not complete the trial because their participation in the study finished before either site broke down. Eighteen patients either partially completed (at least one site broke down) or fully completed (both sites broke down) the trial. In these 18 patients, test sites lasted 3.6 days longer than control sites (95% CI, 1.5-5.8 days; P = 0.002). Twelve patients fully completed the trial. In this group, test sites lasted 3.9 days longer than control sites (95% CI, 0.6-7.2 days; P = 0.025). CONCLUSIONS: The addition of 1 mg dexamethasone to syringe drivers significantly extends the viability time of subcutaneous cannulation sites in palliative care patients.

Telephone counselling as an adjunct to nicotine patches in smoking cessation: a randomised controlled trial.

OBJECTIVES: To investigate the effectiveness of telephone counselling as an adjunct to nicotine replacement therapy (NRT) by transdermal patch in smoking cessation. DESIGN: Randomised controlled trial. PARTICIPANTS AND SETTING: 854 smokers from New South Wales, aged 18 years and older, who had smoked at least 10 cigarettes per day for the past year and responded to newspaper advertisements between October 2001 and January 2002; the trial was conducted between October 2001 and August 2002. INTERVENTIONS: Random allocation to either NRT alone or NRT plus telephone counselling (5 sessions spaced according to a relapse-sensitive call schedule). MAIN OUTCOME MEASURES: Self-reported abstinence assessed by telephone questionnaires at 1, 2, 3 and 6 months: 28-day continuous abstinence at 3 and 6 months, and 90-day continuous abstinence at 6 months. RESULTS: 28-day continuous abstinence rates among participants receiving telephone counselling were significantly greater than among those not receiving telephone counselling at both 3 and 6 months (31.6% v 25.1%; P = 0.04 at 3 months; and 30.1% v 22.4%; P = 0.01 at 6 months). Similarly, 90-day continuous abstinence rates at 6 months were significantly greater for participants receiving counselling (26.7% v 18.6%; P = 0.004). CONCLUSION: Telephone counselling as an adjunct to NRT increases abstinence rates beyond the use of NRT alone.