Lung cancer diagnosed following an emergency admission: exploring patient and carer perspectives on delay in seeking help.

PURPOSE: Compared to others, patients diagnosed with lung cancer following an emergency, unplanned admission to hospital (DFEA) have more advanced disease and poorer prognosis. Little is known about DFEA patients' beliefs about cancer and its symptoms or about their help-seeking behaviours prior to admission. METHODS: As part of a larger single-centre, prospective mixed-methods study conducted in one University hospital, we undertook qualitative interviews with patients DFEA and their carers to obtain their understanding of symptoms and experiences of trying to access healthcare services before admission to hospital. Interviews were recorded and transcribed. Framework analysis was employed. RESULTS: Thirteen patients and 10 carers plus 3 bereaved carers took part in interviews. Three patient/carer dyads were interviewed together. Participants spoke about their symptoms and why they did not seek help sooner. They described complex and nuanced experiences. Some (n = 12) had what they recalled as the wrong symptoms for lung cancer and attributed them either to a pre-existing condition or to ageing. In other cases (n = 9), patients or carers realised with hindsight that their symptoms were signs of lung cancer, but at the time had made other attributions to account for them. In some cases (n = 3), a sudden onset of symptoms was reported. Some GPs (n = 6) were also reported to have made incorrect attributions about cause. CONCLUSION: Late diagnosis meant that patients DFEA needed palliative support sooner after diagnosis than patients not DFEA. Professionals and lay people interpret health and illness experiences differently.

Lung cancer diagnosed following emergency admission: a mixed methods study protocol to improve understanding of patients' characteristics, needs, experiences and outcomes.

BACKGROUND: Lung cancer is the leading cause of death from cancer in England. About 40% of patients with lung cancer are diagnosed following an emergency admission (DFEA) to hospital. DFEA is more common in women, and more likely with increasing age and deprivation. Most have advanced disease and survival is poor, but little else is known about this group. The aim of this study is to obtain a detailed understanding of the characteristics, needs, experiences and outcomes of this group. METHODS/DESIGN: This is a single centre study with quantitative and qualitative work packages (WP). WP1 gathers basic details about all patients diagnosed with lung cancer during a 12 month period, focusing on demographics, diagnostic and treatment pathways and selected outcomes. WP2 obtains information from those patients DFEA or, when unable, their carers, about their holistic needs and experiences, using the Sheffield Profile for Assessment and Referral to Care questionnaire and selected questions from the National Cancer Patient Experience Survey. WP3 uses in-depth qualitative interviews with patients and carers to obtain detailed accounts of their symptoms, help-seeking behaviours prior to admission and subsequent experiences of care. DISCUSSION: Relatively little is known about the experiences of lung cancer patients DFEA and this study will provide detailed information about their needs, characteristics, experiences and outcomes. It should identify areas in the diagnostic and treatment pathway where there is scope to improve the care provided to this group of patients and their carers. The findings will also inform the need for further focused research.

Safer ambulatory syringe drivers: experiences of one acute hospital trust.

In December 2010 the National Patient Safety Agency released a Rapid Response Report citing evidence of harm and death necessitating the need to immediately address safety issues affecting ambulatory syringe drivers with rate settings in millimetres of travel. These devices are widely used in palliative care in the UK, both in the community and in the hospital setting. In order to ensure a successful changeover to a safer system, a coordinated, multidisciplinary, cross-boundary approach is essential. This article outlines the experiences of one acute hospital trust in identifying and trialling ambulatory syringe drivers to potentially adopt, and in implementing the selected driver and training staff in its use. It is hoped that it will provide insight into the challenges of undertaking such a change in practice.

Lung cancer diagnosed following an emergency admission: Mixed methods study of the management, outcomes and needs and experiences of patients and carers.

BACKGROUND: In the UK, although 40% of patients with lung cancer are diagnosed following an emergency admission (EA), data is limited on their needs and experiences as they progress through diagnostic and treatment pathways. METHODS: Prospective data collection using medical records, questionnaires and in-depth interviews. Multivariate logistic regression explored associations between diagnosis following EA and aspects of interest. Questionnaire responses with 95% confidence intervals were compared with local and national datasets. A grounded theory approach identified patient and carer themes. RESULTS: Of 401 patients, 154 (38%) were diagnosed following EA; 37 patients and six carers completed questionnaires and 13 patients and 10 carers were interviewed. Compared to those diagnosed electively, EA patients adjusted results found no difference in treatment recommendation, treatment intent or place of death. Time to diagnosis, review, or treatment was 7-14 days quicker but fewer EA patients had a lung cancer nurse present at diagnosis (37% vs. 62%). Palliative care needs were high (median [IQR] 21 [13-25] distressing or bothersome symptoms/issues) and various information and support needs unmet. Interviews highlighted in particular, perceived delays in obtaining investigations/specialist referral and factors influencing success or failure of the cough campaign. CONCLUSIONS: Presentation as an EA does not appear to confer any inherent disadvantage regarding progress through lung cancer diagnostic and treatment pathways. However, given the frequent combination of advanced disease, poor performance status and prognosis, together with the high level of need and reported short-fall in care, we suggest that a specialist palliative care assessment is routinely offered.

Why is the Liverpool care pathway used for some dying cancer patients and not others? Healthcare professionals' perspectives.

BACKGROUND: Despite evidence suggesting that the Liverpool Care Pathway for the Dying Patient is a structured and proficient means of supporting care delivery in the last hours or days of life, discrepancies in uptake are widespread. This exploratory study sought to understand why patients dying of cancer in oncology wards of one hospital trust were, or were not, supported by the LCP. A purposive qualitative case study design was used; each case represented a patient who had died and their most involved nurse and doctor. In-depth interviews explored both recollections of the 'case' and wider experiences of using the Pathway in end-of-life care. Eleven healthcare professionals were interviewed about their involvement in the end-of-life care of six patients. For four of these patients care was supported by the LCP. FINDINGS: Although doctors and nurses reported they preferred to use the Pathway to ensure comfortable death, an important factor influencing their decisions was time of death. Access to timely senior review was regarded as an essential preliminary to placing patients on the Pathway but delayed access 'out of hours' was commonly experienced and tensions arose from balancing conflicting priorities. Consequently, the needs of dying patients sometimes failed to compete with those receiving curative treatment. CONCLUSIONS: This study suggests that greater attention should be focused on 'out of hours' care in hospitals to ensure regular senior review of all patients at risk of dying and to support front line staff to communicate effectively and make contingency plans focused on patients' best interests.