Effectiveness of structured nursing assessment of symptom distress in advanced lung cancer

PURPOSE/OBJECTIVES: To test the efficacy of structured symptom assessment on level and rate of change in symptom distress over time. DESIGN: Prospective six-month randomized control trial. SETTING: Outpatient oncology offices and clinics in California. SAMPLE: 48 subjects newly diagnosed with advanced lung cancer, predominantly non-small cell. Most subjects received chemotherapy, 50% were women, and their average age was 62 years. 190 observations were analyzed. METHODS: Subjects were assigned randomly to structured assessment or usual care. Both groups completed the Symptom Distress Scale (SDS) monthly. After bivariate screening of potential predictors, a multivariate regression model for level and rate of change in SDS scores was created. MAIN RESEARCH VARIABLES: Symptom distress, functional status, and emotional distress. FINDINGS: Fatigue was the most common severely distressing symptom. In a multivariate model, chemotherapy and systematic assessment were associated with less symptom distress over time. Higher scores in depression and more functional limitations were related to higher levels of overall distress. Weight loss had a small impact. CONCLUSIONS: Systematic use of structured symptom assessment forestalled increased symptom distress over time. Chemotherapy lessened symptom distress, but the impact diminished with time. Subjects with more depression and greater functional limitations had greater symptom distress. IMPLICATIONS FOR NURSING PRACTICE: During the course of advanced lung cancer, systematic ongoing nursing assessment of symptoms may be the first step in enhancing interventions to decrease distress. Patients at highest risk for symptom distress are those who experience emotional distress and functional limitations.     

The meaning and impact of empathic relationships in hospice nursing

This naturalistic field study was designed to explore the patient's perspective of the nature, meaning, and impact of empathic relationships with hospice nurses. The findings are part of a larger study, focused on the meaning and impact of empathic relationships that develop between hospice nurses and their patients. Data were generated through in-depth interviews with 14 terminally ill adults receiving home-based hospice care. According to the hospice patient, an empathic relationship developed through a process of reciprocal sharing and revealing of personhood within a context of caring and acceptance. The experience of an empathic relationship meant being acknowledged as an individual, a person of value. The outcome of the empathic relationships between hospice nurses and their patients was the improvement and maintenance of patients' physical and emotional well-being. Understanding the patient's perspective is critical for effective nursing interventions and meaningful outcomes. Future research needs to explore empathic relationships between the nurse and family caregivers in various settings.     

Ethics consultation

Hospices in the U.S. were surveyed in 1990 to find out whether service to blacks and Hispanics was affected by admission criteria and hospice service characteristics of hospices located in or near these populations. Hospice characteristics such as reimbursement patterns, staff interventions, and admission criteria were different depending upon the percent of blacks and/or Hispanics in the hospice service area or actually served by the hospice. Care for Hispanics was more dependent on Medicaid and free care than blacks whose care was financed primarily by Medicare and Medicaid. Hospices identified problems in serving Hispanics as language, reimbursement, and severity-of-illness issues. Hospice admission criteria, especially the primary caregiver requirement, were identified as impeding access for blacks. Hispanics were perceived as presenting the most access and service problems and as the most underserved.     

Feasible criteria for enrolling end-stage dementia patients in home hospice care

Hospice care is considered appropriate for end-stage dementia patients (Luchins & Hanrahan, 1993), yet less than 1 percent of hospice patients have a primary diagnosis of dementia (Hanrahan & Luchins, 1995). This pilot study tested the feasibility of providing palliative care for dementia patients. A common eligibility requirement for admission to hospice is that the patient is likely to die within six to seven months. The uncertain survival time of dementia patients thus prevents access to hospice programs. Therefore, enrollment criteria were developed based on the characteristics of advanced dementia and a history of medical complications. With these criteria established, it was then possible to enroll 11 patients over two years. The enrollment criteria proved successful in that the median survival time was five months, with an average of seven months. Eight of the 11 patients died during the study. Hospice care was well accepted by family caregivers and appeared to meet the patient's needs.     

Complex genetic contribution of the Apo AI-CIII-AIV gene cluster to familial combined hyperlipidemia. Identification of different susceptibility haplotypes

Considerable attention has focused on describing ethical issues that critical care nurses face in their practice: however, less attention has been directed at describing the process of ethical decision-making. Systematic research linking aspects of ethical-decision making and stress is lacking. This cross-sectional study examines the relationship between selected aspects of ethical decision-making, stress and selected nurse characteristics. Sixty-one critical care nurses completed the Nurse's Ethical Decision Making--ICU Questionnaire and the Health Professions Stress Inventory. Findings revealed that nurses who selected the patient advocacy model had significantly higher nurse autonomy scores, that perceived anxiety had a negative association with nurse autonomy, and that workplace restrictions and stress were related.     

Criteria for enrolling dementia patients in hospice

OBJECTIVE: Because survival time varies greatly, it is difficult for dementia patients to meet a key criterion for eligibility for the Medicare hospice benefit: a 6-month survival time. We have developed criteria for the Medicare hospice benefit that include the characteristics of advanced dementia and related medical complications. The purpose of the study was to determine survival time among dementia patients who met these criteria. Additionally, because the National Hospice Organization (NHO) developed its own guidelines while the study was in progress, we retrospectively examined the application of these guidelines to our sample. DESIGN: Two cohorts of hospice patients were studied longitudinally, each for 2 years. SETTING: Nine Midwestern hospice programs. PARTICIPANTS: Forty-seven patients were enrolled in home hospice and institutional hospice settings. MEASUREMENTS: Survival time consisted of the number of days between enrollment in the hospice program and death or the end of the study. Other measures included Activities of Daily Living, ratings of Appetite, Nourishment, and Mobility, Functional Assessment Staging (FAST), a Medical Complications Checklist, and a care plan concerning the use of medications for acute illness. RESULTS: Our hospice enrollment criteria predicted a median survival time of 4 months and a mean survival time of 6.9 months; 38% of patients survived for more than 6 months. FAST scores and Mobility ratings were significantly related to survival time. However, 41% could not be scored on the FAST as their disease progression was not ordinal. Among patients who could be scored on the FAST and who had reached Stage Seven C, their mean survival time was 3.2 months compared with 18 months among those who could be scored and had not reached this stage and 8.6 months among patients whose disease progression was not ordinal, P < .001. When the palliative care plans were examined, less aggressive care plans resulted in shorter survival times, P < .01. CONCLUSION: Our hospice enrollment criteria identified a group with a median survival time of 4 months and a mean survival time of 6.9 months. Using NHO criteria relying on the FAST allows the identification of a subgroup with very high mortality and a short time until death. Although the FAST can identify a subgroup of appropriate candidates for hospice, sole reliance on this measure might decrease access to hospice care for many dementia patients.     

Postoperative nursing care contributions to symptom distress and functional status after ambulatory surgery

The relationship of postoperative patient-perceived nurse caring behaviors to symptom distress and functional status in 100 adult ambulatory surgical patients was examined. These behaviors explained 9.3% to 18.2% of the variance in functional status on the 1st, 4th, and 7th day postsurgery, and 10% of the variance in symptom distress on the 7th postoperative day after controlling for ASA physical status classification, preoperative symptom distress, and preoperative functional status.     

End-of-life confusion in patients with cancer

PURPOSE/OBJECTIVES: To review the literature on confusion at the end of life, provide accurate definitional and defining characteristics of confusion, and outline nursing strategies for its resolution. DATA SOURCES: Published articles, computerized databases, book chapters, reference lists from chapters and journal articles. DATA SYNTHESIS: As a major component of symptom distress in terminal care, confusion has not been defined clearly and therefore has not benefited from rigorous assessment and study as have other end-of-life symptoms. CONCLUSIONS: Increased knowledge about confusion that occurs in patients with widely metastatic cancer will assist in accurate symptom identification, early recognition, and timely management to reduce cognitive symptom distress at the end of life. Improved symptom resolution also can benefit family coping during terminal care. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can devise management protocols for confused patients that include screening criteria, pharmacologic interventions, environmental support, and prophylactic safety measures.     

Computerized prompts for cancer screening in a community health center

One hundred eleven (58%) of 191 adolescent inpatients previously admitted to the emergency wards at the Child and Adolescent Psychiatric Clinics in the cities of Uppsala and G?teborg participated in a 2-4 year follow-up evaluation. The prevalence, incidence, and stability of depressive symptoms, suicidal ideation, and suicide attempts among the adolescents, and predictors of follow-up functioning were examined. Although a majority of the patients substantially reduced their depressive symptoms over the 2-4 year period, a smaller group (13%), mainly girls (94%), continued reporting high symptom levels at follow-up, and one out of five adolescents had moderate-severe levels of suicidal ideation. The accumulated frequency of suicide attempts among the patients shortly prior to hospitalization and during the follow-up was 59% including two patients who committed suicide. Significant predictors of depressive symptom severity at follow-up were depressive symptom scores and V-diagnoses at inpatient assessment. Previous suicide attempts before hospitalization, high levels of self-reported depressive symptoms and nonintact family status at inpatient assessment predicted suicide attempts during the follow-up period. The high prevalence of attempted and completed suicide in this clinical group underscores the importance of developing effective treatments for suicidal adolescents.     

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.     

Tumor cell recognition by lymphocytes: is the MHC always essential?

More than a year has passed since the Center to Improve Care of the Dying and the Corcoran Gallery of Art sponsored the symposium entitled: A Good Dying: Shaping Health Care for the Last Months of Life. Using the National Hospice Foundation sponsored exhibition, Hospice: A Photographic Inquiry, as a backdrop, the symposium included presentations on the current state of hospice care as well as the obstacles that limit access to hospice care. This article represents an update on many of the activities of the National Hospice Organization and the greater hospice community as we continue to improve access to quality hospice care.     

Transcranial power mode Doppler duplex sonography of intracranial aneurysms

Recent events have challenged our health system to increase access to and provide high quality care for patients near the end of life. Simultaneously, Medicare is developing review policies to determine eligibility for hospice patients with select noncancer diagnoses. The purpose of this study was to determine whether the proposed policies met one of their chief goals: accurate identification of patients with a less-than-six-months prognosis. Only 35 percent of 104 patients who died within six months of admission to the hospice used for this study, LifePath Hospice, met the Medicare proposed criteria for hospice eligibility. The median and mean survival time of the sample was 14 and 30 days respectively. Based on this review, it is recommended that Medicare alter their proposed review policies and not limit access to hospice eligible patients who desire and are in need of such services.     

Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations

Evaluated a low cost and practical intervention designed to decrease children's, parents', and nurses' distress during children's immunizations. The intervention consisted of children viewing a popular cartoon movie and being coached by nurses and parents to attend to the movie. Ninety-two children, 4-6 years of age, and their parents were alternatively assigned to either a nurse coach intervention, a nurse coach plus train parent and child intervention, or a standard medical care condition. Based on previous findings of generalization of adult behaviors during medical procedures, it was hypothesized that training only the nurses to coach the children would cost-effectively reduce all participants levels of distress. Observational measures and subjective ratings were used to assess the following dependent variables: children's coping, distress, pain, and need for restraint; nurses' and parents' coaching behavior; and parents' and nurses' distress. Results indicate that, in the two intervention conditions, children coped more and were less distressed, nurses and parents exhibited more coping promoting behavior and less distress promoting behavior, and parents and nurses were less distressed than in the control condition. Although neither intervention was superior on any of the variables assessed in the study, nurse coach was markedly more practical and cost-effective. Therefore, nurses' coaching of children to watch cartoon movies has great potential for dissemination in pediatric settings.     

Perceptions of symptom distress in lung cancer patients: I. Congruence between patients and primary family caregivers

Part I of this two-part paper employs a comparative design to compare primary family caregivers' assessments of lung cancer patients' symptom distress with patients' own perceptions of symptom distress in the home setting. Part II describes the results of the qualitative component of this research. A convenience sample of 37 patient-family caregiver dyads completed the McCorkle and Young Symptom Distress Scale (SDS). Family caregivers' global scores were moderately correlated with patients' global scores (r = 0.71; P < 0.001). No significant differences in ratings were found for ten of the 13 symptoms assessed. Therefore, when the patient is unable to provide a self-report of symptom distress, health-care professionals may seriously consider family caregivers' assessments of patients' symptom distress to be reasonable estimates for at least ten of the 13 symptoms on the SDS.     

Symptom perception in children with asthma: Cognitive and psychological factors.

Objective: This study tested the differential effects of several cognitive and psychological variables on children's perception of asthma symptoms by use of an Asthma Risk Grid. Children's subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms. Design: The study included 270 children with asthma (ages 7–17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment. Main Outcome Measures: Children's symptom perception scores by use of the Asthma Risk Grid. Results: Children's attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone. Conclusion: Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An examination of the co-morbidity between chronic pain and posttraumatic stress disorder on U.S. Veterans.

The purpose of this study was to assess the comorbidity between chronic pain and posttraumatic stress disorder (PTSD) and examine the extent to which PTSD is associated with changes in the multidimensional experience of pain in a sample of Veterans with chronic pain. It was hypothesized that Veterans with comorbid chronic pain and PTSD would report significantly higher scores on measures of pain intensity, pain behaviors, pain-related disability, and affective distress than Veterans with pain alone. Data were obtained from 149 Veterans who completed self-report questionnaires as part of their participation in a Psychology Pain Management program at a northeastern Department of Veterans Affairs health care facility. Analyses indicated that 49% of the sample met criteria for PTSD. A multivariate analysis of covariance was conducted with age, sex, pain duration, and depressive symptom severity as covariates. In partial support of our hypothesis, the presence of PTSD was found to contribute significantly to measures of affective distress, even after controlling for the effects of depressive symptom severity. The implications of these data are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Importance of Assessing Symptoms and Symptom Clusters in Critical Care Units

In the highly technological environment of critical care, a comprehensive symptom assessment from the patient's perspective is routine. There is a paucity of research related to symptom management in the critical care environment. The lack of understanding of the symptom experience for critical care patients could represent missed opportunities to manage symptoms and minimize suffering. This article discusses the importance of assessing symptoms and symptom clusters in critical care patients and challenges surrounding the assessment of symptom clusters. By understanding symptom clusters, critical care nurses can develop more comprehensive assessments, as well as more tailored intervention strategies.

     

Secondary metabolites from marine microorganisms: bacteria, protozoa, algae and fungi. Achievements and prospects

To facilitate nurses' job satisfaction and reduce their psychological distress, it is useful for a nursing manager to know whether factors within the workplace provide greater prediction of these affective states than variables outside the domain of work, and whether there are common predictors of satisfaction and distress. The relative importance of occupational and nonoccupational variables in the prediction of job satisfaction and psychological distress was investigated in a survey of hospital nurses (N = 376). Perceived relations with the head nurse, coworkers, physicians, and other units/departments, along with unit tenure and job/nonjob conflict, were predictors of job satisfaction. Personal disposition (anxiety-trait), social integration, unit tenure, professional experience, position level, and job/nonjob conflict, along with the relations with the head nurse and physicians, were predictors of psychological distress. The relations with the head nurse and physicians, as well as unit tenure and job/nonjob conflict, were predictors of both satisfaction and distress. The prediction by unit tenure is noteworthy. Unit tenure had a negative relationship to satisfaction and a positive one to distress, whereas total experience had a negative relationship to psychological distress and none with job satisfaction. The role of unit tenure in nurses' affective experiences warrants more attention in future research, along with the role of job/nonjob conflict and other variables predictive of nurses' satisfaction and distress.