Community family medicine teachers' perceptions of their teaching role.

OBJECTIVES: Our study explored community preceptors' perceptions of their teaching role, to better understand effective ambulatory and community-based teaching. METHODS: Bandura's social cognitive theory and Schön's notion of reflective practice guided conceptual development of an interview exploring preceptors' views of their role, teaching goals, teaching techniques, student assessment practices, factors affecting teaching and learning, and balance of patient and student needs. Preceptors reflected also on a significant personal teaching experience. A total of 17 highly student-rated preceptors participated. A trained interviewer conducted each interview; all were transcribed and subjected to content analysis. RESULTS: Preceptors (male, 14; female, 3) described learner-centred approaches, setting goals jointly with the student. Demonstration, guided practice, observation and feedback were integral to the experience. Preceptors saw student comfort in the environment as key to effective learning; they attempted to maximize students' learning and breadth of experience. They wanted students to understand content, "know-how" and "being a family physician". Patients remained the primary responsibility, but learners' needs were viewed as compatible with that responsibility. Many preceptors perceived a professional responsibility as "role models". CONCLUSIONS: Preceptors recognized the dynamic environment in which they taught students, and they described strategies which demonstrated how they adapted their teaching to meet the needs of the learner in that environment. These teachers combined learner-centred approaches with sound educational practices, broad learning experiences, attention to student learning and concern for development of professional expertise and judgement. These findings may assist faculty development in family medicine, and other disciplines, in providing effective ambulatory care teaching.

Identifying potential need for cancer palliation in Nova Scotia.

OBJECTIVE: To assess the degree to which Nova Scotia cancer patients who may need palliative care are being referred to the comprehensive Halifax-based Palliative Care Program (PCP). METHODS: The authors conducted a retrospective, population-based study using administrative health data for all adults in Nova Scotia who died of cancer from 1988 to 1994. Proportions and odds ratios (ORs) were used to determine where there were differences in age, sex, place of residence, cancer cause of death, year of death and use of palliative radiotherapy between those who were referred to the PCP at the Halifax Infirmary and those who were not, and between those who were referred late (within 14 days of death) and those who were referred earlier. RESULTS: Of the 14,494 adults who died of cancer during the study period, 2057 (14.2%) were registered in the PCP. Within Halifax County, 1582 (36.4%) of the 4340 patients with terminal cancer were seen in the PCP. Predictors of PCP registration were residence in Halifax County (OR 19.2, 95% confidence interval [CI] 15.4-23.9), younger age compared with those 85 years of age or older (for those 20-54 years of age, OR 4.9, 95% CI 3.2-7.6; 55-64 years, OR 3.4, 95% CI 2.2-5.1; 65-74 years, OR 3.1, 95% CI 2.1-4.5; 75-84 years, OR 2.1, 95% CI 1.4-3.1), and having received palliative radiation (OR 1.8, 95% CI 1.5-2.2). PCP referral was associated directly with head and neck cancer (OR 5.4, 95% CI 3.0-9.7) and inversely with hematopoietic (OR 0.2, 95% CI 0.4-0.9), lymph node (OR 0.3, 95% CI 0.1-0.4) and lung (OR 0.6, 95% CI 0.4-0.9) cancer. Predictors of late referral (being referred to the PCP within 14 days of death) were age 65-84 years (OR 1.4, 95% CI 1.1-1.8) and 85 years and over (OR 1.8, 95% CI 1.1-3.0), no palliative radiation (OR 2.0, 95% CI 1.4-3.1) and cancer cause of death. People dying within 6 months of diagnosis were somewhat less likely to have been referred to the PCP (OR 0.8, 95% CI 0.6-0.9), but those who were referred were more likely to have been referred late (OR 2.6, 95% CI 2.0-3.5). INTERPRETATION: Referral to the PCP and earlier rather than late referral were more likely for younger people with terminal cancer, those who received palliative radiation and those living closer to the PCP. Referral rates also varied by cancer cause of death and the time between diagnosis and death.

Dehydration and provision of fluids in palliative care. What is the evidence?

OBJECTIVE: To provide a clinical review of issues surrounding reduced fluid intake in palliative care patients and a practical approach to care for these patients. DATA SOURCES: Medline was searched from 1980 to 1995 for articles concerning dehydration in dying patients. In addition, the law databases QUICKLAW, WESTLAW, and MEDMAL were searched. STUDY SELECTION: Key papers were included for discussion in relation to the clinical evidence to treat or withhold treatment and to a representative sample of the social, ethical, and legal issues. SYNTHESIS: There is little clinical evidence to guide patients, families, or clinicians in treating with reduced fluid intake during the terminal phase of life. Assisting patients to take fluids as a social or symbolic act is recognized, as is the ethical and legal stance that assisting fluid intake should be thought of as a medical therapy. CONCLUSION: Without sound evidence upon which to base clinical decisions, patients, families, and clinicians are left to balance potential benefits and burdens against the goals of care.

Evaluating a palliative care program: methodology and limitations.

The article describes an evaluation of a palliative care service in a regional and tertiary care facility. The service components are described. The four outcomes chosen for evaluation were: (a) symptom relief; (b) satisfaction with care for patients/families; (c) utilization of community resources; (d) good nursing morale and low staff stress. Quality of life was measured using a symptom distress scale; satisfaction using an adapted Kristjanson FAMCARE scale; community resources with opinion and satisfaction surveys; and staff morale and stress with the Maslach Bumout Inventory and Latack's Coping Questionnaire. Results showed that overall symptom distress was reduced. Patients/families were generally satisfied, with some areas needing attention. Physicians were generally satisfied and believed patients/families benefited from the psychosocial support, respite, and education/information. Nurses felt they had the time, energy, resources and support to give quality care.

Dehydration symptoms of palliative care cancer patients.

A cross-sectional survey of inpatient palliative care subjects (n = 52) was performed to determine the severity and distribution of symptoms thought to be associated with dehydration in terminally ill cancer patients and to clarify the association between the severity of these symptoms and commonly used objective measures of dehydration. Each patient rated the severity of seven symptoms using 100-mm visual analogue scales. The symptoms considered were thirst, dry mouth, bad taste, nausea, pleasure in drinking, fatigue, and pain. Associations were sought between these symptoms and predictor variables (fluid intake, plasma osmolality, sodium, and urea) and confounding variables (age, medications, oral disease, and mouth-care regimen). Mean symptom ratings were thirst 53.8 mm, dry mouth 60.0 mm, bad taste 46.6 mm, nausea 24.0 mm, pleasure in drinking 61.6 mm, fatigue 61.8 mm, and pain 33.5 mm. Using multiple-linear regression, no association could be demonstrated between thirst (the principal outcome of interest) and the predictor or confounding variables. Estimates of the study power performed after completion revealed a 76% chance of detecting a 20-mm difference between high and low fluid intake groups. This study provides the first quantitative estimate of the experience of dehydration symptoms in those with advanced cancer. The symptoms appear to be rated moderately severe, but there is no demonstrable association between severity and fluid intake. Further studies with greater statistical power and more accurate hydration assessment would strengthen our understanding of this association.

[Not Available]. / Liquides IV et le mourant hospitalisé

The authors examined charts for evidence of the use of intravenous fluids in all patients who died from malignant disease occurring in a tertiary care teaching hospital during a 1-year period. Total lengths of stay and survival time after obtaining "do not resuscitate" orders were longer in those who died without intravenous fluids. More than two-thirds of patients with cancer who died in hospital did so with an intravenous line.

Intravenous fluids and the hospitalized dying: a medical last rite?

The authors examined charts for evidence of the use of intravenous fluids in all patients who died from malignant disease occurring in a tertiary care teaching hospital during a one-year period. Of 106 patients who were identified, 86 received intravenous fluids within their last 30 days of life, and 73 died with an intravenous line running.Intravenous fluid use appeared to be independent of age, sex, language, presence of family members, primary tumour site, presence of metastases, duration of illness, and presence of a "no cardiopulmonary resuscitation" order. Total lengths of stay and survival time after obtaining "do not resuscitate" orders were longer in those who died without intravenous fluids. More than two-thirds of patients with cancer who died in hospital did so with an intravenous line.

Palliative care in medical education at McMaster University.

As professionals working within palliative care struggle to find their niche in the academic, administrative and service continuum of patient care, we have a growing desire to share what has been learned with students and colleagues. The opportunities for student physicians to learn the principles and practices of caring for the dying are few. The described curriculum content is dependent on the McMaster philosophy of medical education and the developmental level of the student physician. Areas included are: philosophy of palliative care, communication skills, symptom assessment and control, approach to ethical issues, decision making and interdisciplinary team function. The authors describe the university's current approach in its specific contribution to undergraduate and postgraduate medical education, the continuum throughout those years and an examination of recommendations for the future.