Laycarers can confidently prepare and administer subcutaneous injections for palliative care patients at home: A randomized controlled trial.

BACKGROUND: Palliative care patients consistently nominate home as their preferred care environment. This is challenging without support from laycarers, especially if patients require subcutaneously administered symptom relief. Laycarers typically lack confidence with this task and request professional guidance. AIM: To explore differences in laycarers' confidence in administering subcutaneous injections depending upon whether a laycarer, registered nurse or pharmacist prepared injections for subsequent administration by laycarers. DESIGN: Prospective randomized controlled trial with three intervention arms: laycarer prepares, labels and stores injections; registered nurse prepares injections; and pharmacist prepares injections for later administration by laycarer. SETTING/PARTICIPANTS: In all, 93 laycarers, from 24 urban and rural community services, completed the study. RESULTS: The primary outcome of interest was laycarer confidence with injection administration; analysis of variance revealed no significant differences between the three intervention arms; mean values ranged from 5.9 to 6.1 out of 7 ( F(2, 90) = 0.50, p = 0.61). Comparison of confidence after laycarer preparation versus other (nurse or pharmacist) was not statistically significant ( t = 0.7, df = 90, p = 0.49). Averaged over intervention arms, confidence levels increase significantly with injecting experience, from 5.3 to 6.1 ( F(1, 75) = 47.6, p < 0.001). CONCLUSION: Upskilled laycarers can confidently administer subcutaneous injections for loved ones, regardless of who prepares injections. This finding can improve patient outcomes and potentially decrease unwanted admissions to inpatient facilities.

Intuition versus cognition: a qualitative exploration of how women understand and manage their increased breast cancer risk.

Risk comprehension in individuals at increased familial risk of cancer is suboptimal and little is known about how risk is understood and managed by at-risk individuals who do not undergo genetic testing. We qualitatively studied these issues in 36 unaffected women from high-risk breast cancer families, including both women who had and had not undergone genetic testing. Data were collected through semi-structured interviews and data analysis was guided by Grounded Theory. Risk comprehension and risk management were largely influenced by the individual's experience of coming from a high-risk family, with both tested and untested women relying heavily on their intuition. Although women's cognitive understanding of their risk appeared generally accurate, this objective risk information was considered of secondary value. The findings could be used to guide the development and delivery of information about risk and risk management to genetically tested and untested individuals at increased risk of hereditary cancer.

Facilitators and Challenges in Psychosocial Adaptation to Being at Increased Familial Risk of Breast Cancer.

Little is known about the process of psychosocial adaptation to familial risk in tested and untested individuals at increased familial risk of cancer. This paper presents findings from a qualitative study of 36 women participating in the Kathleen Cuningham Consortium for Research into Familial Breast cancer (kConFab) Psychosocial study. Facilitators and challenges in psychosocial adaptation were identified through semi-structured interviews. The women, who were either tested (carriers or non-carriers of breast cancer susceptibility mutations) or untested (ineligible for testing or eligible but delayed or declined testing), described personal, support network and healthcare characteristics that impacted on the adaptation process. Challenges in one domain could be overcome by facilitators in other domains and key differences relating to whether women had undergone testing, or not, were identified. Tested and untested women with an increased familial risk of breast cancer may benefit from support tailored to their mutation testing status in order to enhance adaptation.

Depression in palliative care patients: a survey of assessment and treatment practices of Australian and New Zealand palliative care specialists.

OBJECTIVE: To explore the practices of members of the Australian and New Zealand Society of Palliative Medicine (ANZSPM) in assessing and treating depression in palliative care patients. METHODS: Semistructured questionnaires were forwarded to ANZSPM members in consecutive mail-outs to survey diagnostic and treatment practices for depression. RESULTS: The response rate was 62.3%. The median prevalence of depression, as perceived by respondents, in the present respondent patient populations was 20% (range 0%-90%); 57.1% of respondents always assessed for depression, whereas 42.9% assessed for depression sometimes. The majority (98.9%) of respondents relied on clinical interviews to assess depression; non-somatic symptoms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria were more useful than somatic symptoms. The depression screening tools most frequently used were one- and two-item questions. Pharmacological and non-pharmacological methods were used to treat depression, with selective serotonin reuptake inhibitors the most frequently prescribed medications. Psycho-educational and supportive counselling were the most frequently used non-pharmacological interventions. Nominated measures to augment depression management included improving access to psychiatry, psychology and other allied health services, the development of a screening tool specific to palliative care patients and associated guidelines for depression management. CONCLUSIONS: This is the first Australasian study to explore the practice of medical practitioners regarding depression in palliative patients. Incorporation of screening tool questions into palliative care assessment interviews may warrant future research. WHAT IS KNOWN ABOUT THE TOPIC? Depression in palliative care patients has a negative impact on quality of life; however, little is known about how Australasian palliative care medical practitioners manage depression in this patient population. WHAT DOES THIS PAPER ADD? To the researchers' knowledge, this is the first Australasian study that explores the practices of local palliative care specialists in the management of depression in palliative patients. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Overall management of depression in palliative care populations by Australasian practitioners is similar to that of their European colleagues. Consensus is that for assessment of depression in palliative patients, non-somatic symptoms of DSM-IV criteria are more useful than somatic symptoms. Practitioners report the need for improved access to psychiatric, psychological and other support services, for a palliative care-specific depression screening tool and for depression management guidelines applicable to palliative care patients.

Distress in unaffected individuals who decline, delay or remain ineligible for genetic testing for hereditary diseases: a systematic review.

OBJECTIVE: Reviews on the psychosocial aspects of genetic testing for hereditary diseases typically focus on outcomes for carriers and non-carriers of genetic mutations. However, the majority of unaffected individuals from high-risk families do not undergo predictive testing. The aim of this review was to examine studies on psychosocial distress in unaffected individuals who delay, decline or remain ineligible for predictive genetic testing. METHOD: Systematic searches of Medline, CINAHL, PsychINFO, PubMed and handsearching of related articles published between 1990 and 2012 identified 23 articles reporting 17 different studies that were reviewed and subjected to quality assessment. RESULTS: Findings suggest that definitions of delaying and declining are not always straightforward, and few studies have investigated psychological distress among individuals who remain ineligible for testing. Findings related to distress in delayers and decliners have been mixed, but there is evidence to suggest that cancer-related distress is lower in those who decline genetic counselling and testing, compared with testers, and that those who remain ineligible for testing experience more anxiety than tested individuals. Psychological, personality and family history vulnerability factors were identified for decliners and individuals who are ineligible for testing. CONCLUSIONS: The small number of studies and methodological limitations preclude definitive conclusions. Nevertheless, subgroups of those who remain untested appear to be at increased risk for psychological morbidity. As the majority of unaffected individuals do not undergo genetic testing, further research is needed to better understand the psychological impact of being denied the option of testing, declining and delaying testing.

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.

SMS reminders increase on-time vaccination in Aboriginal and Torres Strait Islander infants.

Abstract: Timely immunisation is important to protect children from communicable diseases. However, immunisation uptake in Aboriginal and Torres Strait Islander children under the age of two years is often lower than in non-Indigenous children. This contributes to the gap in health outcomes between Aboriginal and Torres Strait Islander children and non-Indigenous children. We have tested the effectiveness of short message service (SMS) reminders in improving timeliness of childhood immunisation in Aboriginal and Torres Strait Islander infants in regional Queensland, Australia. Reminders were sent to parents of Aboriginal and Torres Strait Islander children, at five immunisation age milestones: six weeks, four months, six months, 12 months, and 18 months. There was a significant improvement in the proportion of children vaccinated on-time (within 30 days of the due date), compared to an earlier age cohort, at all milestones except 12 months. The absolute risk difference (ARD) of on-time vaccination between the two cohorts ranged between 4.7% (95% confidence interval [95% CI]: 1.1-8.2%, at six weeks) and 12.9% (95% CI: 7.4-18.5%, at six months). The likelihood of on-time vaccination (rate ratio, RR) in the intervention group compared to the control group ranged from 1.05 (95% CI: 1.01-1.10, at six weeks) to 1.31 (95% CI: 1.14-1.50, at 18 months). SMS reminders were associated with an improvement in immunisation timeliness in Aboriginal and Torres Strait Islander infants at all age milestones measured except 12 months.

The development of novel interventions to assist the leaders of cancer support groups.

PURPOSE: The literature on cancer support groups supports the provision of ongoing education and training for cancer support group leaders, with evidence suggesting that more skilled and experienced leaders create better outcomes for group members. To address support and training needs reported by leaders, three novel interventions were developed and pilot-tested. These included a leaders' website and discussion forum, DVD and manual, and a 2-day training workshop. METHODS: The interventions were developed using a combination of literature review, expert consensus, and consumer feedback. A convenience sample of ten leaders pilot-tested the Website and discussion forum. Using a mixed-method approach, evaluation of the workshop and the DVD and manual was conducted with 35 leaders. RESULTS: Overall, satisfaction with all aspects of the Website and discussion forum was high. Analysis of the quantitative data revealed extremely high satisfaction with the workshop and DVD and manual. The qualitative responses of workshop participants further supported the quantitative findings with enhanced knowledge, understanding, and confidence reported by leaders. CONCLUSIONS: All three interventions exhibited a high degree of user acceptance, regardless of the skill or experience of the cancer support group leader. The overall positive findings from the evaluation of the leader Website and discussion forum, the DVD and manual, and the workshop for cancer support group leaders provides evidence to support more rigorous evaluation of these resources in a randomized controlled trial.

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.

Predictors of breast cancer screening behavior in women with a strong family history of the disease.

This study applied the self-regulation model to examine cognitive and emotional predictors of screening in unaffected women with a strong family history of breast cancer. 748 unaffected female members of an Australian registry of multiple-case breast cancer families formed the sample. Participants completed a baseline psychosocial questionnaire and a screening questionnaire 3 years later. Multinomial logistic regression was employed to determine predictors of under- and over-screening according to national guidelines. At follow-up 16% of women under-screened and 10% over-screened with mammography; 55% under-screened with clinical breast examination (CBE); and 9% over-screened with breast self-examination (BSE). Of the women found screening according to guidelines for mammography 72% reported ever having received specific recommendations for mammography screening from a health professional. Compared to appropriate screeners, under-screeners on mammography were less likely to have received a screening recommendation (as were under-screeners on CBE), were younger and reported lower perceived breast cancer risk, but were at higher relative risk (RR) of breast cancer and were more likely to report elevated depression. Over-screeners on mammography were more likely to be younger and have a lower RR of breast cancer. Over-screeners on BSE reported elevated cancer-specific anxiety, were less likely to be university educated and more likely to have received a recommendation for BSE. Under- and over-screening is common in women with a strong family history of breast cancer. Evaluation of interventions targeting perceived risk of breast cancer, anxiety and depression are needed to ensure women obtain accurate advice from relevant specialists and enact screening recommendations.

Shared decision making in oncology: assessing oncologist behaviour in consultations in which adjuvant therapy is considered after primary surgical treatment.

INTRODUCTION: Shared decision making (SDM) is now considered a desirable goal in health care, yet little is known about current practice in cancer care, and its impact on patient outcomes. This study aimed to develop an oncology-specific coding system for SDM, explore variations in SDM according to patient and disease characteristics, determine the relationship between SDM and patient satisfaction with the consultation, and explore the impact of SDM on patient anxiety. METHODS: Sixty-three medical and radiation oncology consultations with patients with primary cancer involving consideration of adjuvant therapy after surgery were audio-taped, transcribed and coded. Intra and inter-rater reliability of the coding system was 95 and 90% respectively. Patients completed questionnaires before and after the consultation. RESULTS: Construct validity of the SDM coding system was successfully conducted. Oncologists demonstrated on average under 11 of 18 SDM behaviours. Behaviours seeking patient preferences were particularly rare. SDM behaviours were more apparent in consultations involving female breast cancer patients. SDM behaviour scores in combination with patient involvement preference could predict achievement of patient involvement preference but not overall patient satisfaction. Although there was no overall relationship between patient anxiety and SDM scores, it did appear that physicians may change SDM behaviour according to patient factors including anxiety. CONCLUSION: Our findings reinforce the importance of the doctor in facilitating shared decision making in oncology consultations.

Exploring the impact of training on the experience of Australian support group leaders: current practices and implications for research.

BACKGROUND: Existing literature suggests that the effectiveness of a support group is linked to the qualifications, skills and experience of the group leader. Yet, little research has been conducted into the experiences of trained vs. untrained support group leaders of chronic-illness support groups. The current study aimed to compare the experience of leaders, trained vs. untrained in group facilitation, in terms of challenges, rewards and psychological wellbeing. METHODS: A total of 358 Australian leaders of cancer and multiple sclerosis (MS) support groups, recruited through State Cancer Councils and the MS society (response rate of 66%), completed a mailed survey. RESULTS: Compared with untrained leaders, those with training were significantly younger, leading smaller groups and facilitating more groups, more frequently (all P < 0.05). Trained leaders were more likely to be female, educated beyond high school, paid to facilitate, a recipient of formal supervision and more experienced (in years) (all P < 0.01). Untrained leaders reported more challenges than trained leaders (P < 0.03), particularly struggling with being contacted outside of group meetings (52%) and a lack of leadership training (47%). Regardless of level of training, leaders identified a number of unmet support and training needs. Overwhelmingly, leaders found their facilitation role rewarding and the majority reported a high level of psychological wellbeing. CONCLUSIONS: Group facilitator training has the potential to reduce the burden of support group leadership. Developing interventions to assist support group leaders will be particularly beneficial for leaders with minimal or no training group facilitation training.

Maternally focused worry.

Emerging evidence suggests that many women in the postnatal period experience clinically significant levels of anxiety but do not meet full diagnostic criteria for an existing anxiety disorder. In this study, 167 women with infants aged 2 weeks to 12 months were interviewed for current and lifetime history of depression and anxiety disorders using the SCID-I and completed a range of self-report measures measuring psychological risk factors and current depressive and anxiety symptomatology. Qualitative comments provided by women diagnosed with ADNOS (maternally focused worry) were analyzed and themes identified, and independent t-tests and chi-square tests were conducted to compare differences between these women and women with GAD. Results showed (1) there to be almost as many women who met criteria for ADNOS (maternally focused worry) as met criteria for GAD, and (2) that women with maternally focused worry were indistinguishable from women with GAD in terms of anxiety and depressive symptom severity, functional impairment and a range of risk factors. These results highlight the status of maternally focused worry as an under-recognized phenomenon and one in need of further clinical and research attention.

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.

Prevention of postnatal distress or depression: an evaluation of an intervention at preparation for parenthood classes.

OBJECTIVES: To determine the effectiveness of a psychosocial intervention, provided to expectant couples in routine antenatal classes, on the postpartum psychosocial adjustment of women and men. DESIGN: A 3*3 between subjects randomised control design was utilised. The two factors were condition and self-esteem. Preparation for Parenthood programs were randomly allocated to one of three conditions: usual service ('control'), experimental ('empathy'), or non-specific control ('baby-play'). The latter condition controlled for the non-specific effects of the intervention, these being: the provision of an extra class; asking couples to consider the early postpartum weeks; and receiving booster information after the antenatal class, and again shortly after the birth. Women and men were categorised into three levels of self-esteem, as measured antenatally: low, medium and high. METHODS: 268 participants were recruited antenatally. Interview data and self-report information was collected from 202 of these women at 6 weeks postpartum, and 180 women at 6 months postpartum. The intervention consisted of a session focusing on psychosocial issues related to becoming first-time parents. Participants discussed possible postpartum concerns in separate gender groups for part of the session, and then discussed these issues with their partners. Hypothetical scenarios depicting stressful situations in the early postpartum weeks for women and men were discussed, with solutions that parents have found useful given to the participants. In the non-specific control condition, the session focused on the importance of play with a baby, with videotapes and discussion around how parents can play with infants. RESULTS: At 6 weeks postpartum there was a significant interaction effect between condition and self-esteem on maternal adjustment. Women with low self-esteem, who had received the intervention, were significantly better adjusted on measures of mood and sense of competence than low-self-esteem women in either of the two control conditions. There were no main or interaction effects by 6 months postpartum. The beneficial effect at 6 weeks was related to partners of these women being more aware of how the mother was feeling, and with women reporting greater satisfaction with the sharing of home and baby tasks. There were no significant main or interaction effects for men at either time point, other than men with low self-esteem reporting poorer adjustment. CONCLUSIONS: This brief and inexpensive intervention was effective in reducing postpartum distress in some first-time mothers at 6 weeks postpartum. The effectiveness of this intervention was related to an increased level of awareness in the men as to how their partners were experiencing the early postpartum weeks. That the effect was only evident for women who, antenatally, reported being low in self-esteem, is an important advance in our knowledge of the effectiveness of such prevention programs. No previous studies have investigated the differential effectiveness of such programs depending upon the woman's level of self-esteem, and this finding indicates that future work should measure this variable. These findings should be understood in the context that the population sampled were those attending preparation for parenthood classes, and thus different interventions will be needed for couples who do not attend such classes. This brief psychosocial intervention can be readily applied to antenatal classes routinely conducted in hospitals or the community.

Psychosocial factors and uptake of risk-reducing salpingo-oophorectomy in women at high risk for ovarian cancer.

Bilateral risk-reducing salpingo-oophorectomy (RRSO) has been shown to significantly reduce the risk of ovarian cancer. This study assessed factors predicting uptake of RRSO. Women participating in a large multiple-case breast cancer family cohort study who were at increased risk for ovarian and fallopian tube cancer (i.e. BRCA1 or BRCA2 mutation carrier or family history including at least one first- or second-degree relative with ovarian or fallopian tube cancer), with no personal history of cancer and with at least one ovary in situ at cohort enrolment, were eligible for this study. Women who knew they did not carry the BRCA1 or BRCA2 mutation segregating in their family (true negatives) were excluded. Sociodemographic, biological and psychosocial factors, including cancer-specific anxiety, perceived ovarian cancer risk, optimism and social support, were assessed using self-administered questionnaires and interviews at cohort enrolment. RRSO uptake was self-reported every three years during systematic follow-up. Of 2,859 women, 571 were eligible. Mean age was 43.3 years; 62 women (10.9 %) had RRSO a median of two years after cohort entry. Factors predicting RRSO were: being parous (OR 3.3, p = 0.015); knowing one's mutation positive status (OR 2.9, p < 0.001) and having a mother and/or sister who died from ovarian cancer (OR 2.5, p = 0.013). Psychological variables measured at cohort entry were not associated with RRSO. These results suggest that women at high risk for ovarian cancer make decisions about RRSO based on risk and individual socio-demographic characteristics, rather than in response to psychological factors such as anxiety.

Sign the e-petition opposing the increase in registration fees.

The NMC proposes to increase our annual registration fee to £120. It is not an organisation, like a union or professional association, that we would choose to join or contribute to.

Lack of benefit from paracetamol (acetaminophen) for palliative cancer patients requiring high-dose strong opioids: a randomized, double-blind, placebo-controlled, crossover trial.

CONTEXT: The adjunctive use of paracetamol (acetaminophen) with strong opioids has become entrenched practice in palliative care pain management, despite little evidence to support its use. OBJECTIVE: The study aim was to investigate potential analgesic benefits of 4 g of paracetamol daily for palliative cancer patients requiring high-dose opioids. METHODS: Thirty-one patients, using at least 200mg of oral morphine equivalent daily, were recruited to a prospective, double-blinded, randomized, crossover trial. Patients received usual medications plus 4 g of paracetamol or placebo for five days each in random order. Primary outcome, effect on pain, was assessed using daily diaries, including a numerical rating scale (NRS) from zero (no pain) to 10 (unbearable) and recording numbers of breakthrough analgesics. Secondary outcomes-nausea, vomiting, cognitive impairment, constipation, and overall well-being--were assessed using the NRS. Data from the last four days of each treatment were analyzed. Patients also indicated in which part of the study their pain was better controlled. RESULTS: Twenty-two patients, requiring a median dose of 255 mg of oral morphine equivalent daily, completed the trial. There were no significant order or treatment-by-order interaction effects for any variable; paired t-tests were conducted to investigate change in mean levels on outcome variables with placebo vs. paracetamol. For none of the variables was there a statistically significant difference when assessed with placebo compared with paracetamol. No change approached clinically significant levels, with a mean difference in rated pain of 0.16, and mean difference of 0.42 for a number of breakthrough medications. Fifteen patients were undecided whether paracetamol improved pain. CONCLUSIONS: These data do not support the common practice of adding regular paracetamol daily as an adjunct to high-dose opioids for pain control in cancer patients receiving palliative care.