Improving end-of-life care through quality improvement.

Although end of life (EoL) care has been identified as an area for quality improvement in hospitals, the quality of care Canadian patients receive at the end of life is not well-evidenced. National statistics indicate that Canadians would prefer to die at home, yet more than 50% die in acute care hospital settings. Busy and often highly specialised acute care units may be perceived as a distressing place of death for both patients and their families. Furthermore, many clinicians are not trained in diagnosing imminent dying, managing symptoms at the end of life or supporting dying patients and their families. As such, to improve the experience of EoL care, a corporate, institution-wide strategy entitled the Quality Dying Initiative was introduced and implemented across a tertiary care academic teaching hospital. A primary focus of this initiative was the implementation of a comprehensive Comfort Measures Strategy. This strategy involved the development of an evidence-based order set, which included elements of symptom assessment and management, patient and family education, and spiritual and emotional support. Staff education and mentoring was also a critical element of the larger Comfort Measures Strategy, as well as an evaluative component.

An interprofessional education programme for medical learners during a one-month palliative care rotation.

Interprofessional education in health care and in palliative care has been the focus of increasing attention in recent years. For health professionals to provide and deliver high-quality palliative care, collaboration and teamwork is required. Palliative care is the ideal service to introduce interprofessional teamwork to medical learners early on in their training. During a 1-month palliative care rotation in Ontario, Canada, medical learners completed a questionnaire seeking their feedback on the interprofessional team model. This article will highlight the results of the questionnaire, how the team promotes a culture of interprofessional collaborative practice, and the supportive structures that foster collaboration among professionals.

Enhancing communication in end-of-life care: a clinical tool translating between the Clinical Frailty Scale and the Palliative Performance Scale.

OBJECTIVES: To create a clinical tool to translate between the Clinical Frailty Scale (CFS), which geriatrics teams use, and Palliative Performance Scale (PPS), which palliative care teams use, to create a common language and help improve communication between geriatric and palliative care teams. DESIGN: Cross-sectional. SETTINGS: Two academic health centers: inpatient palliative care and chronic care units, an outpatient geriatric clinic, and inpatient referrals to a palliative care consultation service. PARTICIPANTS: Older adults (≥65) aged 80.9±8.0, with malignant (51%) and nonmalignant (49%) terminal diagnoses (N=120). MEASUREMENTS: Each participant was assigned four scores: a CFS score each from a geriatric physician and nurse and a PPS score each from a palliative care physician and nurse. Interrater reliability of each measure was calculated using kappa coefficients. For each measure, the mean of physician and nurse scores was used to calculate every possible combination of CFS and PPS scores to determine the combination with maximum agreement. RESULTS: Interrater reliability of each measure was very high for the CFS (weighted κ=0.92) and PPS (weighted κ=0.80). The CFS-PPS score matching that achieved maximum agreement (weighted κ=0.71) was used to create a conversion chart between the two measures. CONCLUSION: This conversion chart is a reliable means of translating scores between the CFS and PPS and is useful for geriatric and palliative care teams collaborating in the care of elderly adults.

Nurses' experiences caring for patients and families dealing with malignant bowel obstruction.

Malignant bowel obstruction (MBO) is a well-recognised complication of advanced abdominal and pelvic cancers. Often surgical intervention is not feasible, resulting in complex symptoms and an unpredictable course. Although symptom management is a crucial part of nursing care, psychosocial and emotional issues frequently emerge for patients and families. This qualitative study explored the perspectives of nurses from a palliative care unit, in-patient acute care oncology units, ambulatory cancer setting, and the community on their experiences of caring for patients with MBO and their families. Six individual interviews and two focus groups were conducted. Eight overarching messages were identified related to nurses' experiences. Highlights include aspects of patients' and families' emotional distress, and the nurse-patient relationship in relieving suffering. Nurses have an important and privileged role that involves identifying MBO signs and symptoms, having knowledge of treatment and symptom management options, and helping patients transition from a curative to a palliative philosophy of care.

What do symptom scores mean: observations on discrepancies when defining symptoms using words and numbers.

UNLABELLED: The Edmonton Symptom Assessment System (ESAS) has become a more frequently used tool for symptom screening in oncology and palliative care settings in Ontario. The process patients use to select symptom scores however is poorly understood. PURPOSE: The purpose of this paper is to consider what patients mean when assigning numbers or words to symptoms, and the implications for healthcare providers who interpret these responses. METHODS AND SAMPLE: A previously conducted study in our organization asked four hundred inpatient and ambulatory oncology patients to rank ESAS symptoms with the usual numerical responses (0-10) and then with word phrases of 'none', 'mild', 'moderate', or 'severe' to examine the relationship between chosen numbers and words. KEY RESULTS: Although results showed a strong positive correlation between number and word rankings for each ESAS symptom, closer examination revealed that for some patients there were discrepancies between chosen numbers and words, with broad numerical ranges, particularly for the words 'mild' and 'moderate'. Through a secondary analysis, these discrepant responses are explored and relevant literature is presented that highlights the importance of understanding patients as they communicate their symptoms. CONCLUSIONS: Health care providers need to be aware of the potential for discrepancies when reviewing patient self-reported data. Numbers and words may not fully capture a patient's symptom burden; further exploration is required to gain a more comprehensive understanding of a patient's current state of being.

Addressing the sexual health needs of patients with gynecologic cancers.

Research indicates that sexual health and function frequently are overlooked by healthcare professionals despite being identified as an essential aspect of patient care. This article discusses the topic of sexuality as it pertains to women with gynecologic cancers, highlights barriers to addressing sexuality with patients with cancer, and provides nurses with a framework to guide them in providing information and support to patients who are experiencing sexual difficulties or who need information about sexual function. A case study addresses the challenges a woman with cervical cancer faces and the role of the nurse in supporting the patient and her partner within the PLISSIT model.

Pain management at the end of life in a patient with renal failure.

Literature indicates that an essential element of a 'good' death is the absence of pain. Achieving a pain-free death for the patient who discontinues dialysis is a goal shared by patient, family and care providers. Pain management at end of life can be challenging, especially in the setting of renal failure. Aspects of assessment and pharmacological management of pain in the dying patient are explored through the use of a case study. Through investment in ongoing relationships with their patients, and striving to build knowledge and skills in pain management, nephrology nurses promote excellence in end-of-life patient care.