Issues in prison hospice: toward a model for the delivery of hospice care in a correctional setting

This paper examines issues in prison hospice care based on the author's nine years experience as a prison hospice worker and trainer and on data gathered by the National Prison Hospice Association (NPHA) from a number of federal and state prison medical facilities with operational or developing hospice programs, including both scatter-bed and hospice unit models, employing inmate hospice volunteers and the services of outside community hospice agencies and volunteers. The paper discusses DNR orders and curative vs. palliative care decisions, pain management, AIDS care, interdisciplinary care teams, staff and volunteer training and supervision, and the need for compassionate early release and community placement programs. The author proposes a set of preliminary guidelines for the delivery of hospice care in the correctional setting.     

Enhanced production of IL4 but not of IFN gamma and IL 10 by peripheral blood mononuclear cells from atopic children in response to CD2 plus CD28 stimulation

Because individuals with mental retardation have recently been identified as a group at-risk for developing HIV infection, HIV/AIDS training programs for service providers working with this population are critical. In this study an HIV/AIDS education program for family-based foster care providers was described and evaluated. The results indicate that although these service providers had some prior knowledge about HIV and AIDS, there were significant improvements in knowledge following the training. Implications of these findings for individuals with mental retardation were discussed.     

How common is medical training in palliative care? A postal survey of general practitioners

BACKGROUND: General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home. AIM: To evaluate the training in palliative care GPs have received throughout their careers. METHOD: Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals. RESULTS: A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor. CONCLUSIONS: There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.     

Dying and death in an acute-care medical hospital

Nowadays, more people seem to die in hospitals or other establishments than in their own homes. The following paper reports on 50 consecutive cases of death that occurred in a clinic of internal medicine. The analysis concentrated on the circumstances, the symptoms and the treatment of the patients during the 12 h. preceding and immediately before death as well as on the opinion of the relatives and the attending staff. A questionnaire registered the different opinions. Nearly a third of these deaths occurred after a fairly short hospitalization time. Death was not always the result of a long illness and it involved also young people. Most of the patients died in their hospital room, in the presence of their relatives and/or of the attending staff. They were mostly unconscious during the moments preceding their death. Terminal symptoms such as pain, anxiety, shortness of breath or thirst were largely kept under control. The relatives and concerned people were, as far as possible, informed about the grievance and the fatal issue of the patient's illness. Their reactions were diverse. Most relatives were satisfied with the treatment and care given to the hospitalized patient. The doctors and nursing staff considered their working together as being better than usually expected. Clear therapeutical concepts, appropriate palliative care as much as optimal communication are important requirements for a good treatment of the dying. The following results allow us to question many a prejudice concerning death in a hospital surrounding, but also show us possibilities of improvement. So we should sometimes question ourselves about the sense and the need of certain nursing interventions. We should spend more time during our medical training on the question of palliative care and on the problem of the relationship of doctors to death and to the dying. We feel that establishing a "science of death" or a segregation of the dying in specialized institutions makes no sense.     

A 12-year study (1975-1986) of mortality in methadone-maintenance patients: selected demographic characteristics and drug-use patterns of AIDS and non-AIDS-related deaths

This paper describes changes in demographic characteristics and drug use patterns of persons who died while enrolled in a New York City methadone-maintenance program during the years preceding and subsequent to the AIDS epidemic. Persons dying from AIDS were more likely to be younger, Hispanic, and male than those dying from other causes. Drug use increased during the 12-year study period, and the spread of the HIV infection among drug users may be reflected in an increased use of injectable drugs.     

Teaching Rwandan families to care for people with AIDS at home

AIDS causes disabling symptoms during its chronic and terminal phases. Families throughout the world, whether related to the patient by blood or affection, provide most of the personal care for him or her at home during these phases. Whether the family has access to advanced medical care or not, they can be taught simple comfort measures and nursing care skills that will improve the well-being of the patient. In Rwanda, a small country in east-central Africa, Red Cross volunteers were trained to teach these skills. The volunteers then returned to their villages to help local families. Six months later, 24 of these families were interviewed about the impact of the volunteers' visits. Families indicated they had benefited from being taught the caregiving skills. They also appreciated the emotional support attendant to the volunteers' visits. In summary, the training course enabled volunteers both to enhance family nursing care skills and to provide emotional support to families caring for people with AIDS at home. This training can also be used by volunteers to assist families caring for members ill with other endemic chronic infectious diseases.     

Palliative medicine: a new specialty changes an old debate

The specialty of palliative care, of which palliative medicine is part, has developed from hospice care for the dying and aims to meet the various needs of those suffering from advanced incurable progressive disease. Specialist palliative care is not expensive and can be made available to all those who need it, at home, in hospital or in a hospice. Arguments in favour of permitting euthanasia for those dying as a result of a chronic disease are usually based on compassion respect for autonomy or perceived hypocrisy in existing medical practice. Each of these arguments is examined and found wanting.     

Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life

The confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers.     

Meeting the social service needs of persons with AIDS: hospices' response

A national sample of 148 directors of hospice social service departments (or persons most familiar with the delivery of social services in the hospice) participated in an exploratory study investigating the effects of the acquired immune deficiency syndrome (AIDS) epidemic on the delivery of hospice social services. Findings suggest, as does the literature, that the psychosocial needs of persons dying from AIDS present different challenges than those of traditional hospice patients. Furthermore, the results indicate the need for greater collaborative efforts among community agencies as well as specific and ongoing training for staff and volunteers who work with persons with AIDS (PWAs). Implications for the delivery of hospice social services to this population are discussed.     

Palliative care. An integral part of life's end

While the needs of dying individuals and their families have come under increasing scrutiny in the past decade, issues related to the needs of older adults (75 years or more) who are dying have not been systematically addressed. Death and dying are increasingly associated with old age, yet the conceptualization of palliative care in later life is not well developed. All too often, the philosophy and principles of palliative care are not invoked in the care of people who are both old and dying. It is an omission that must cease.     

Evaluation of a palliative care service: problems and pitfalls

OBJECTIVE: To evaluate a palliative care home support team based on an inpatient unit. DESIGN: Randomised controlled trial with waiting list. Patients in the study group received the service immediately, those in the control group received it after one month. Main comparison point was at one month. SETTING: A city of 300,000 people with a publicly funded home care service and about 200 general practitioners, most of whom provide home care. MAIN OUTCOME MEASURES: Pain and nausea levels were measured at entry to trial and at one month, as were quality of life for patients and care givers' health. RESULTS: Because of early deaths, problems with recruitment, and a low compliance rate for completion of questionnaires, the required sample size was not attained. CONCLUSION: In designing evaluations of palliative care services, investigators should be prepared to deal with the following issues: attrition due to early death, opposition to randomisation by patients and referral sources, ethical problems raised by randomisation of dying patients, the appropriate timing of comparison points, and difficulties of collecting data from sick or exhausted patients and care givers. Investigators may choose to evaluate a service from various perspectives using different methods: controlled trials, qualitative studies, surveys, and audits. Randomised trials may prove to be impracticable for evaluation of palliative care.     

Barriers to effective palliative care of terminal patients. An international perspective

Barriers to palliative care around the world include: underutilization of and lack of access to opiates; the separation of palliative (hospice) care from the usual health care system in much of the world; cultural barriers to discussing death and dying; and, especially for the developing countries, financial barriers to good palliative care. Palliative care education for health care providers, pain initiatives as well as flexibility and adaptation of palliative care principles to local resources may help overcome these barriers.     

Review of Transitions in Dying and Bereavement: A Psychosocial Guide for Hospice and Palliative Care.

Reviews the book by the Victoria Hospital Society et al (2003), which describes what palliative and bereavement counselors do and how they do it. The specific goal was to examine the psychosocial needs and care of individuals who are dying or bereaved, with the ultimate goal being the improvement of the quality of palliative psychosocial care services. The major strength of the book is the wealth of practical knowledge addressing the needs of dying individuals and their families, particularly if the family members are adults. The sensitive and caring approach described throughout the book gives the reader a great sense of respect for those clinicians who have mastered the art of treating dying individuals and their families with dignity and compassion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluating the quality of after death care

Nursing care rarely ceases following a patient's death. The project described in this article concerns the quality of nursing care delivered to patients following their death. The author concludes that the quality of care depends in large part on whether staff received training in the care of dying patients.     

Evaluation of fracture predilection in the calcaneus after external fixator pin removal

Slovakia is a country with no tradition of home care services and a long history of regarding death and dying as taboos and therefore institutionalising them. Increased attention to palliative care issues has resulted in some important changes, to the benefit of patients in need of palliative care. These include general availability of oral slow-release forms of strong opioids (cost completely reimbursed by the insurance companies), a developing network of home care agencies, and increased attention to the needs of palliative patients, especially among oncologists and pain specialists. In February 1995 the Department of Palliative Care was established within the National Cancer Institute in Bratislava. It has 19 in-patient beds and also an out-patient clinic. Although the primary goal is the improvement of the quality of life, several approaches that can prolong life without worsening its quality are also used. These include laser destruction of intraluminal gastrointestinal tumours, insertion of intraluminal stents, brachyradiotherapy, pleurodeses, percutaneous gastrostomy, percutaneous nephrostomy, palliative chemotherapy, treatment of hypercalcaemia. In 1995 the Palliative Care Section of the Association for Study and Treatment of Pain was established, as was the first Hospice Foundation.     

What is the future of palliative medicine in Germany?

Traditional medical treatment approaches for incurably and terminally ill persons are often felt by the patients and their families to be lacking, since distressing physical and spiritual symptoms of the disease cannot be adequately addressed. In many cases, care in the final stage of life represents a complex medical challenge whose objective is to maintain an individually sufficient quality of life for the patient. New strategies for therapy and care evolving out of the international hospice movement have entered medical training programs under the heading of palliative medicine. Although palliative medicine has only recently enjoyed increasing acceptance in professional as well as lay circles in Germany, it is widespread in many Anglo-Saxon countries, where it also is offered as an academic discipline in research and teaching. According to the most recent American legal interpretations, palliative treatment has been approved as a constitutional right for patients with severely debilitating symptoms. Against the background of sweeping social restructuring, demographic and tumor-epidemiological developments are exerting increasing pressure on our modern societies to improve treatment approaches for incurable patients. In the public itself a changed and more open treatment of the topics of death and dying is becoming apparent, resulting in a demand as well for medical treatment options. From all this, as well as the fact that Germany has been strongly hesitant to establish palliative medicine facilities, it is apparent that there is a clear need to catch up in the area of palliative medicine treatment, research and teaching. The current mood of fiscal restraint in health care may delay medical progress, but it will not be able to prevent it.     

Palliative care in undergraduate medical education. Status report and future directions

OBJECTIVE: To describe the status of palliative care education in the undergraduate medical curriculum and to offer recommendations for improvement. DATA SOURCES: Review of literature on palliative care and of recently submitted grants on medical education for end-of-life care. STUDY SELECTION: English-language reports of educational programs targeted toward medical students were examined, as well as surveys of medical schools. DATA EXTRACTION: Studies were reviewed by the authors to assess the quality of the educational program, evaluation methodology, and conclusions. From over 9000 citations on palliative care and related topics that were retrieved from MEDLINE searches from 1980 through 1995, and from reviewing 14 palliative care journals published from 1985 through 1996, 310 articles were identified that addressed medical education for end-of-life care, and 180 were carefully examined. DATA SYNTHESIS: While nearly all medical schools offer some formal teaching about end-of-life care, there is considerable evidence that current training is inadequate, most strikingly in the clinical years. Teaching about palliative care is received favorably by students, positively influences student attitudes, and enhances communication skills. However, curricular offerings are not well integrated; the major teaching format is the lecture; formal teaching is predominantly preclinical; clinical experiences are mostly elective; there is little attention to home care, hospice, and nursing home care; role models are few; and students are not encouraged to examine their personal reactions to these clinical experiences. CONCLUSIONS: The increasing attention to palliative care education has created major opportunities for improving education about care at the end of life. Educational programs should be rigorously evaluated to identify best educational practices.     

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to compare levels of death anxiety and coping responses in palliative care and accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative care and 20 from A & E) were recruited from a district general hospital and nearby hospice. Both sites had the same mean annual death rate of 150 patients. Death anxiety was measured by the Death Attitude Profile-Revised Questionnaire and coping responses were elicited by a semi-structured interview. As hypothesized, hospice nurses had lower death anxiety and they were more likely to recall both good and difficult experiences related to patient care. Unlike the hospice nurses, a subgroup (20%) of A & E nurses reported that they were unable to discuss problems with colleagues. The study has implications for the development of institutional support for staff to enable nurses to provide good quality care for dying patients and bereaved people.