Palliative Care (aka End of Life Care). Please complete the Pre-test prior to beginning Case#5. Please see the attached case – read and complete the questions – in paragraph form. Please use the APA sample paper for Title Page, include citations/references where appropriate.
Running head: ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
1
APA Format Template: Title of Paper Goes Here Not Bold 12 pt. Font
Your Name
Old Dominion University
Author Note
Your contact information goes here. An Example is as follows:
Your Name, College of Health Sciences, Department of Community and Environmental Health,
Old Dominion University.
Correspondence concerning this article should be addressed to Your Name, College of Health
Sciences, Department of Community and Environmental Health, Old Dominion University,
Norfolk, VA 23529.
Contact: your name @odu.edu
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
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Title of Paper Repeated Exactly As It Appears On Title Page
To use this template, begin the body of your paper (your introduction) as the first
paragraph beneath the title. Note that APA does not use the Introduction header: just plunge in.
Add your text and delete the placeholder text used in the template. The rest of the text in this
template provides hints about properly generating all the parts of your APA-formatted paper.
APA style specifies that major components of the paper (abstract, body, references, etc.)
each begin on a new page with the heading centered at the top of the page. The body of the text
is typically divided into sections with headings such as Method, Results, and Discussion. For an
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http://www.apastyle.org/manual/related/sample-experiment-paper-1.pdf. Some papers have
multiple studies in them so the body could have multiple sections and subsections within it.
Sections can be further divided into subsections with headings. Use suitable
headings/subheadings for the topic discussed in each of the Case Studies. Unlike in earlier
editions of the APA manual, the sixth edition tells you to bold headings (but not the title above
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designate a subsection of a major section; a Level 3 heading (indented ½”, sentence style caps,
bold font, ends with a period, runs into paragraph text) designates a subsection under a Level 2
heading, and so on. Most student papers will use no more than three levels of headings.
The five levels of headings are shown below.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
Level 1: Major Section With Upper and Lowercase
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
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Heading Level 1
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Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Heading Level 1
Level 2: Flush Left Margin
Level 3: Sentence style caps, runs into text. One space and then start your paragraph
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Heading Level 1
Level 2: Flush Left Margin
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3
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
4
Level 4: Like above but set in italics .This level is rarely used in student papers.
Level 5:Similar to Levels 3 and 4, but not bold. This level is rarely used in student
papers.
Citations and References
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work, and ideas of others on which you are building your argument. The Reference section starts
on a separate page after the body text of the paper. If you need help formatting citations or
references, check out the APA Quick Reference Guide that is available on the School of Social
Work website: http://ssw.unc.edu/files/web/pdf/APA_Quick_Reference_Guide.pdf
About a References Section
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select all the references at once (and nothing else) and apply the hanging indent.
Tables and Figures
Check with your instructor about whether you should embed tables and figures in the text
or attach graphic elements at the end of the paper. If your instructor asks that you attach tables
and figures on separate pages at the end of the text (typical format for papers being submitted for
publication) then the manuscript order is Title Page, Body Text, Reference Section, Appendix (if
any) , Tables, and Figures.
APA format for tables omits the gridlines. See the APA Quick Reference Guide for table
formatting rules. In addition, if you need instruction on creating tables in Word, you’ll find a
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
5
variety of helpful videos posted on YouTube. I recommend the following tutorial for creating
tables in Word http://www.youtube.com/watch?v=0KVBaM4N3zw If you find a helpful
resource, please pass along the information to the Writing Support Team at
SoSWwritingsupport@gmail.com
Table 1
Correlations Among and Descriptive Statistics for Key Study Variables
Dist.
M (SD)
Sex
1.53 (.50)
Age
31.88 (10.29)
Income
2.60 (1.57)
Education
3.44 (1.06)
Relig.
1.21 (.30)
Dist. Intol.
3.75 (1.19)
Sex
Age
Income
Educ.
Relig.
Intol.
.07
-.09
.02
.14
.06
.08
.19*
.20*
.01
.04
-.14
-.09
-.29*
-.06
-.19*
Note. N’s range from 107 to 109 due to occasional missing data. For sex, 0 = male, 1 = female.
BHF = babies hoped for. Dist. Intol. = distress intolerance. Relig. = religiosity.* p < .05.
Using Headers in Word
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
6
Your paper’s page number and running head are located in the Header section of the
page. To edit the Header section, click on the “Insert” tab and choose the Header or Footer
option that looks like the figure below.
Selecting the Header icon will open a drop-down box; select “Edit Header” from the
bottom of the box. Enter your running head, and then close the Header section by clicking on the
red box at the far right of the Word ribbon.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
7
References
Ajournalarticle, R. H., & Seabreeze, R. M. (2002). Example of journal article reference
entry :Title of article goes here, sentence-style caps, no italics. Journal Title in Italics and
Headline Style Caps, 22, 236-252. doi:10.1016/0022-006X.56.6.893
B’authorsurname, I. M. (2010). Example of a book reference: Book title in sentence style caps
and italics. Publisher city, ST: Publisher. doi:10.1016/0022-006X.56.6.893
Cmagazinearticle, B. E. (1999, July). Note that names on this page also identify what kind of
source it is: Each source type has to be formatted in a different way. [Special issue].
Prose Magazine, 126 (5), 96-134.
Donlinemagazineornewsletterarticle, B. E. (1999, July). Did you notice alphabetical references.
[Special issue]. Hot Prose, 126 (5). Retrieved from http://www.hotprose.com
Gbookreference, S. M., Orman, T. P., & Carey, R. (1967). Writers’ book. New York, NY: Lu
Press.
O’encyclopedia, S. E. (1993). Words. In The new encyclopedia Britannica (vol. 38, pp. 745758). Chicago: Forty-One Books.
Qchapter, P. R., & Inaneditedvolume, J. C. (2001). Scientific research papers. In J. H. Stewart &
J. M. Kimmel (Eds.), Research papers are hard work but boy, are they good for you (pp.
123-256). New York, NY: Lucerne.
Rnewspaper articles without authors appear to sharply cut risk of schizophrenia. (1993, July 15).
The Washington Post, p. A12.
ALL CAPS SHORT TITLE 50 CHARACTERS OR LESS
Frugality
Amount that
Gets Spent
on Alcohol
8
Alcohol
Consumption
Figure 1. This simple path model, adapted from results in a Journal of Consumer Behaviour
paper, is an example of a figure.
American Journal of Hospice and Palliative
Medicine®
http://ajh.sagepub.com
Review Article: End-of-Life Care for Old People: A Review of the Literature
Ingrid Agren Bolmsjo
Am J Hosp Palliat Care 2008; 25; 328 originally published online May 7, 2008;
DOI: 10.1177/1049909108315910
The online version of this article can be found at:
http://ajh.sagepub.com/cgi/content/abstract/25/4/328
Published by:
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American Journal of Hospice
& Palliative Medicine®
Volume 25 Number 4
August/September 2008 328-338
© 2008 Sage Publications
10.1177/1049909108315910
http://ajhpm.sagepub.com
hosted at
http://online.sagepub.com
Review Article
End-of-Life Care for Old People:
A Review of the Literature
Ingrid Agren Bolmsjo, PhD, BTh
The aim of this study was to make an inventory of various aspects of end-of-life care of the old people. An
additional aim was to illuminate gaps in existing
knowledge. A systematic literature review focusing on
intervention studies was carried out. Three concepts
were of special interest: end-of-life care, palliative
care, and terminal care. The result encompassed 29
studies, and the articles were grouped together under
4 headings: education and support for close relatives,
education and support for staff, education and support
for patients, and articles dealing with care planning.
The result highlights the need for further research
regarding end-of-life care in geographical and cultural
settings that differ from those in the USA, needs of old
people (ie, 80+), preferences concerning end-of-life
care, and the effect of adjusted and generalizable palliative care models.
A
A literature search of the PubMed (2007) database focused on end-of-life care, palliative care, terminal care, and individuals at the age of 65 and
above. The articles found dealt with problems concerning symptom control, decision making and preferences, the location for dying and death, roles of
the family members, and how palliative care should
be organized. For example, in a study by Lidstone
et al,5 patients suffering from lung cancer and brain
tumors reported severe difficulties and concerns,
which implies a need for better symptom control.
Another problem area concerns the place of death as
terminally ill patients often change their preferences
when the need for care increases.6 The preferences
of patients are influenced by the burden of treatment, that is, the length of hospital stay, extent of
testing, and invasiveness of interventions. Thus,
when planning the care, the staff should be aware of
the importance of preferences of patients with
regard to the burden of treatment.7 The preferences
of dying patients in hospitals are at risk of being overlooked, although 72% of the patients were aware that
they were considered to be dying.8 The authors
underline the importance of evaluating end-of-life
decision making and care to facilitate the transition
from life-sustaining treatment to palliative care.
The roles of the family members concerning
decision making and palliative home care have been
lthough death and dying are a natural part of
life, the increase in the number of very old
people implies challenges for those responsible for their care. For example, most of the very old
people have multiple, as well as chronic, diseases,
which necessitate frequent hospitalization.1
Little research has been conducted on very old
people and the last period of their life.2 However,
Nahm and Resnick3 focused on elderly individuals
and the importance of giving them opportunities to
discuss their end-of-life preferences. In terms of
treatment preferences, the results of their study
indicate that many older people do not want invasive
interventions but prefer comforting measures.
Moreover, their preferences may change over time;
therefore, it is essential to reevaluate them regularly.
The use of intensive care at the end-of-life increases
with age and with the number of coexisting chronic
illnesses.4 As mentioned previously, old people have
specific care needs. Therefore, it is essential to provide them with adjusted interventions.
From the Faculty of Health and Society, School of Health and
Society, Malmo University, Sweden.
Address correspondence to: Ingrid Agren Bolmsjo, School of
Health and Society, Malmo University, Sweden; e-mail: ingrid.
bolmsjo@mah.se.
328
Keywords:
review
end-of-life care; palliative care; old people;
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End-of-Life Care for Old People / Bolmsjo
studied by Stajduhar and Davies.9 The authors found
that fulfilling a promise to the patient to care for
him or her at home, wanting to maintain a normal
family, and previous negative experiences of institutional care influenced the decisions of the family
members. Factors associated with home versus institutional death are discussed in an article by Gallo
et al.10 The authors found that being married,
female, white, living in a higher income area, type
of cancer, and health-resource factors were associated with dying at home rather than in a hospital.
Factors that can influence the transition to a hospice are discussed by Schulman-Green et al.11
Results from interviews with primary caregivers
revealed themes related to experiences of the transition to a hospice: acceptance of the impending
death by the caregiver, challenges in negotiating
health care system along the process of care, and
changing patient–family dynamics.
More knowledge of end-of-life care of old people
is needed to plan and organize care. In particular, it
is important to describe and make an inventory of
end-of-life care to date. However, to study the attitudes of the old people and wishes concerning their
last period of life is also important. If there are discrepancies between existing end-of-life care and
preferences of the old people, it is essential to
describe and analyze them. The approach of the
present article was to gather information concerning
how old people spend their last days, as well as how
they would prefer to spend this period. A new, comprehensive literature review may serve as an orientation in this complex area.
Aim
The aim of this article was to describe and make an
inventory of various aspects of end-of-life care of the
old people. An additional aim was to identify gaps in
scientific knowledge.
Method
The literature search in the PubMed database was
carried out in steps. In the first step, the search was
limited to articles written in English and to individuals who are at the age of 65 and above, after which
Medical Subject Headings (MeSH)-terms were identified. Three concepts were of special interest: endof-life care, palliative care, and terminal care, one of
which had to be a key concept (MeSH Major Topic)
329
of the articles. The search was finalized in December
2007 and resulted in the following articles:
end-of-life care (MeSH Major Topic [(majr]) = 523
articles
palliative care (majr) = 3216 articles
terminal care (majr) = 3633 articles
When combining these 3 concepts, the result was:
end-of-life care (majr) or palliative care (majr), or
terminal care (majr) = 6505 articles.
To identify the most relevant of the abovementioned articles, a search was made for the term
intervention in either the title or abstract. The abbreviation (tiab) was used in the search string: intervention (tiab) or interventions (tiab), which resulted in
51 672 articles. The 2 literature searches were combined with AND, giving a total of 522 articles.
Finally, a limitation in terms of time was decided
upon, and articles written before 1990 were
excluded. Altogether, the searches yielded 497 references. In the second step, the abstracts were
reviewed in relation to the purpose of the study, after
which 126 articles were closely scrutinized in terms of
their relevance and scientific strength.12 The inclusion criteria were that the study should refer to interventions in the context of end-of-life care and people
at the age of 65 and above. Studies dealing with
specific diseases, as well as those mainly focused
on life-sustaining treatments, terminal sedation, and
euthanasia, were excluded. Thus, in the third step,
the 126 studies were evaluated in relation to the
inclusion and exclusion criteria, resulting in 29
studies. Finally, scientific strength was evaluated by
the Goodman model,12 which contains criteria
related to internal and external validity, reliability,
and critical discussion.
Results
Twenty-nine studies were included (Table 1), which
were summarized and grouped with respect to the
content of interventions and for whom they were
intended.
Education and Support for Close
Relatives
Hudson et al13 studied 106 family caregivers of dying
patients. The aim was to examine the effect of a psychoeducational intervention for this group. The
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330
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Schrader SL et al (2002)20
Study design without controls.
Data were collected from patients,
their families, and the hospital
records; N = 50 patients
Weekly visits over a 6-wk-period from
an experienced advisor
Symptom management, spiritual
dialogue, psychosocial counseling,
and guidance on advance directives
A specialist nurse assisted in
symptom control and facilitated
communication and decision making
A prospective cohort study,
randomized design; N = family
members of 767 terminally ill
patients
A GHQ-28 questionnaire
Baker R et al (2000)18
Walsh K et al (2007)19
COPE intervention training
A 3-group comparative design;
N = 329 patients
McMillan SC and Small BJ (2007) 17
Interviews
The Living with Hope program
Concurrent triangulation, pretest and
posttest design; N = 61 patients
Qualitative study; N = 10
Duggleby W et al (2007)15
Henriksson A and Andershed B
(2007)16
Comprehensive palliative care
interventions
Home visits, phone calls, and
questionnaires
Interventions
Cluster randomized trial; N = 183
family members
Randomized controlled trial;
N = 106 family caregivers
Design
Summary of Findings
Ringdal GI et al (2001)14
Hudson PL et al (2005)13
Study
Table 1.
(continued)
Improvements were found in pain,
nonpain symptom management,
psychosocial QoL measures, and
perceptions of communication and
treatment during hospitalization
Intervention group reported a more
positive experience of caregivers.
No effects were observed with
respect to preparedness for providing
care, self-efficacy, competence,
and anxiety
The grief reactions decreased over
time, but there were no differences
between the intervention and control
group
Benefits in fostering hope in family
caregivers
The ability of the relatives to handle
the situation with a terminally ill
family member increased
Symptom distress decreased
significantly in the intervention
group
16% reported dissatisfaction
with patient comfort and 30%
dissatisfaction with communication
and decision making
The help of an advisor had little effect
Findings
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331
Harp music
Randomized experimental study;
N = 80
Nonexperimental study; N = 65
patients
Hilliard E (2003)27
(continued)
A vigil could form part of palliative
care for dying patients.
Music therapy sessions
Case studies of patients with a
terminal illness; N = 84 patients
Ratner E et al (2001)26
Freeman L et al; (2006)28
Formally structured social work visits
to the homes of the patients to
discuss end-of-life issues
Pilot trial, randomized study;
N = 61 patients
Schwartz CE et al (2002)25
Stillman et al (2005)24
Staff training, integration of palliative
care and support, consultation with
an expert nurse
Patient and health care provider discussed ACP (advance care planning)
with a trained nurse
Chart review; N = 1169 residents
Hanson CL et al (2005)23
A questionnaire; N = 6 nursing homes
Faculty observers including doctors, a
nurse ethicist, and a social worker
observed the skills of the trainees in
discussing end-of-life issues with
seriously ill patients.
Recruitment and training of palliative
care leadership teams
Pilot test, observational study;
N = 60 residents
Han PK et al (2005)22
Improved pain and symptom management was reported. Only 29% were
hospitalized, 7% were admitted to
critical care/an ICU, 48% used
hospice care, and 38% were likely
to die at home
The CEX was positively valued by
residents.
Findings
No differences in the use of pain
medication. Hospice enrollment,
pain assessment, prescriptions for
nonpharmacological pain treatment,
and discussions with residents about
end-of-life care increased in the
intervention group
More problems in providing
palliative care were identified in
the intervention group
The intervention group showed higher
congruence between patients and
providers in the understanding of the
end-of-life care preferences of the
patients
82% wanted the care to be provided at
home, 75% of the deaths occurred at
home or in a hospice, 61% used
home, residential, or nursing home
based services.
Higher QoL in the intervention group
Comprehensive adaptable
life-affirming longitudinal
(CALL) care
Interventions
Prospective observational study;
N = 295 patients and families
Design
London MR et al (2005)21
Study
Table 1. (continued)
332
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Individualized assessment, advice,
psychological support, symptom
control and evaluation
(eg, appropriate analgesia)
Use of a modified STAS
All patients were followed on a daily
basis by a member of the PCT and
multidisciplinary rounds were
performed once a week
Palliative care clinic
A home-based palliative care program
A nonequivalent control group study;
N = patients
An assessment schedule and
questionnaire; N = 352 patients
A posttest-only control group design;
N = 49 older people
A prospective pilot study; N = 50
patients
Pilot study. A chart audit tool (CAT)
was used to review medical records;
N = 6 units
Prospective audit study; N = 211
patients
Chart review; N = 100 patients
Comparative group design, N = 558
patients
Jack B et al (2003)30
Edmond PM (1998)31
Gutheil IA and Heyman JC (2005)32
Lambing A et al (2006)33
Bookbinder M et al (2005)34
Morita T et al (2005)35
Casarett DJ et al (2002)36
Brumley RD et al (2003)37
A CD-ROM containing topics such as
taking charge, obtaining comfort,
and reaching closure
Educational program for staff,
implementation strategies, and
evaluation-feedback tools.
Three group sessions with educational
and support components
Letters containing palliative care
recommendations
Interventions
Nonblinded, prospective comparison
trial; N = 135 residents
Design
Jerant AF et al (2004)29
Study
Table 1. (continued)
(continued)
Most patients needed at least one of
the team services, information about
prognosis being the most common
The intervention group was more satisfied with the services, had fewer
emergency department visits, hospital days, skilled nursing care days,
and physician visits compared with
the control group. The palliative care
group had reduced costs compared
with the controls.
PCAD can serve as an educational
tool, be implemented in hospital
units, have a positive impact on outcomes, promote proactive symptom
assessment and treatment, and units
not directly involved in the intervention may also experience change.
There were significant improvements
in many symptoms among the PCT
patients
E-STAS may be a useful tool for
evaluating interventions
The intervention had an influence on
advance communication about
wishes pertaining to the end-of-life
phase
90% were satisfied with the CD-ROM.
The TLC model may be beneficial
when conducting further
interventions
The intervention group had a greater
improvement in all symptoms,
particularly pain and anorexia
Findings
333
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Standard versus in-home palliative
care plus standard care
The palliative care program integrated
primary care physician, consultations, case management, volunteer
and group support, chaplaincy consultation, and artistic expression
Data on patient demographics,
diagnoses, key symptoms, and
outcome were collected by the
APCS; N = 3712 patients
A randomized controlled trial;
N = 298
Controlled study, cluster
randomization; N = 90 patients
Santa-Emma PH et al (2002)39
Brumley R et al (2007)40
Rabow MW et al (2004)41
56.9% were transferred to the APCS,
16.3% were directly admitted, 26.9%
were seen in consultation. The most
common symptom was dyspnea
(53.9%) and 88.7% had 1 to 3
symptoms.
The intervention group reported an
improvement in satisfaction with
care, and its members were more
likely to die at home.
The comprehensive care team resulted
in less dyspnea and anxiety in addition to greater spiritual wellbeing but
failed to improve pain or depression.
More intervention patients than
controls died at home (25% vs 15%)
Findings
Abbreviations: APCS, acute palliative care service; CEX, palliative care clinical evaluation exercise; COPE, creativity, optimism, planning, expert information; E-STAS,
expanded STAS; GHQ-28, general health questionnaire; ICU, intensive care unit; PCAD, palliative care for advanced disease; PCT, palliative care team; QoL, quality of
life; STAS, support team assessment schedule.
A palliative medicine unit, where the
palliative team served as a link to the
community. Guidelines were used to
facilitate the interaction between
services, and education was provided
to community professionals
Consultations, direct transfers, and
admissions, involving the emergency
department, home hospice, and
referring physician
Interventions
Cluster randomized trial; N = 434
patients
Design
Jordhoy MS et al (2000)38
Study
Table 1. (continued)
334
American Journal of Hospice & Palliative Medicine® / Vol. 25, No. 4, August/September 2008
intervention was provided by nurses and consisted of
2 home visits, telephone calls, and questionnaires.
The result showed that the participants perceived
the caregivers in a more positive light. However, no
effects concerning preparedness to provide care,
self-efficacy, competence, or anxiety were observed.
Ringdal et al14 investigated family members to
examine grief reactions when a loved one had died
of cancer. The intervention consisted of comprehensive palliative care. The findings revealed no differences between the intervention group and controls.
In 2 separate studies, the authors examined a living with hope program15 and a support group program for relatives who had a terminally ill family
member.16 The results of both studies showed that
the programs may be useful tools in helping relatives
cope with their situation when caring for a terminally ill loved one.
The COPE (creativity, optimism, planning,
expert information) intervention was tested on family caregivers of the hospice homecare patients.17
The main finding was that distress decreased among
caregivers who had been trained to manage the
symptoms of the patients.
Baker et al18 studied the factors associated with
family satisfaction, such as symptom control, communication, and decision making. The authors
found that 16% of respondents were dissatisfied
with patient comfort and 30% with communication
and decision making.
Walsh et al19 evaluated the effectiveness of
increased support for distressed informal carers. A
trained advisor visited the informants once a week
for a period of 6 weeks. No significant differences
were found.
One article had a double perspective20; the interventions were directed toward both patients and
families and included symptom management, spiritual dialogue, psychosocial counseling, and guidance on advance directives. The main findings
showed improvements in symptom management,
psychosocial quality of life (QoL) measures, and
perceptions of communication and treatment.
London et al21 evaluated whether CALL (comprehensive, adaptable, life affirming, longitudinal)
care had any effect on seriously ill patients and their
families. The authors found that apart from
improved pain and symptom management, 29%
were hospitalized, 7% were admitted to critical care,
48% received hospice care, and 38% were likely to
die at home.
Education and Support for Staff
An educational trial was conducted in a study by
Han et al22 that aimed at testing CEX (palliative care
clinical evaluation exercise): an intervention to
teach trainees the communication skills, including
end-of-life issues. The results indicated that CEX
appear to be a useful educational tool.
The aim of the study by Hanson et al23 was to
test whether a quality improvement intervention in
nursing homes increases hospice, pain management, and advance care planning. The intervention
included the training of palliative care leadership
teams, facilitating meetings for team members, and
educational sessions for staff. The findings showed
that although the use of pain medication remained
unchanged, hospice enrollment, pain assessment,
prescriptions for nonpharmacological pain treatment, and discussions with residents about end-oflife care increased in the intervention group.
Stillman et al24 carried out a study in which the
aim was to determine whether a comprehensive palliative care program in nursing homes would affect
staff knowledge and attitudes. The intervention consisted of staff training, integration of palliative care
principles, support, and consultation with an expert
nurse. The authors concluded that the intervention
group was more open to problems encountered in the
provision of palliative care compared with controls.
In the study conducted by Schwartz et al,25 the
intervention was aimed at both health care personnel and patients. The benefit of discussing advance
care planning with a trained nurse was evaluated.
The result showed increased agreement between
health care professionals and patients, concerning
the latters’ end-of-life care preferences.
Education and Support for Patients
Ratner et al26 examined whether the formally structured visit of the social worker to homes of the
patients in the end-of-life phase made it easier to
discuss issues related to dying and death. The
authors found that 82% wished for the care to be
provided at home, 75% of deaths occurred at home
or in a hospice and that 61% used home, residential,
or nursing home services.
Hilliard27 and Freeman et al28 examined the
effect of music therapy in terminally ill patients. In
both the studies, the music therapy sessions
improved the QoL of the patients.
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End-of-Life Care for Old People / Bolmsjo
Jerant et al29 carried out a study involving very old
people. The study was based on the T (time and team
oriented) L (longitudinal) C (collaborative and comprehensive) model. One main finding was that the
patients placed a higher value on QoL than on prolonging life.
Jack et al30 investigated whether a hospital-based
palliative care team could improve the symptoms of the
cancer patients by psychological support and appropriate analgesia. The results showed that pain and anorexia
decreased for patients in the intervention group.
Edmond et al31 investigated the use of a modified STAS (support team assessment schedule). A
total of 352 patients participated in the study.
Ninety-three percent of patients reported psychological distress on referral, 73% anorexia, 59% pain,
and 59% mouth discomfort.
Gutheil and Heyman32 carried out a study aimed
at evaluating an intervention to help older people
communicate their wishes with regard to end-of-life
care. Three sessions containing education and support had a positive effect on advance communication about these wishes.
Lambing et al33 evaluated a CD-ROM containing topics such as taking charge, finding comfort,
and reaching closure. Ninety percent of the patients
were of the opinion that a CD-ROM could be a useful and complementary tool.
Articles Dealing With Care Planning
Bookbinder et al34 conducted a study on palliative
care for advanced disease (PCAD). The intervention
consisted of an educational program, implementation strategies, and evaluation of the feedback tools.
The main findings indicated that PCAD can serve as
a useful educational tool.
Morita et al35 compared the patients referred to
a palliative care team (PCT) with a multidisciplinary
approach and to a palliative care unit (PCU). All
patients were followed on a daily basis by a member
of the PCT, and multidisciplinary rounds were performed once in a week. The authors found that
there were significant improvements in many symptoms among the PCT patients.
Interventions including a palliative care clinic
(PCC) were assessed in a study by Casarett et al.36
The clinic provided consultations about symptom
management, hospice eligibility, information about
services, as well as advance care planning. The findings showed that most of the patients required at
335
least 1 of the team services, the most common being
a need for information about the prognosis.
Brumley et al37 investigated the effect of a palliative care program on end-of-life care. The results
showed that patients who were included in the intervention group were more satisfied with services and
had fewer emergency department visits, skilled nursing facility days, and physician visits, which led to a
45% reduction in health care costs.
A palliative care unit was examined in a study by
Jordhoy et al.38 In the intervention group, 25% died
at home compared with 15% of the controls.
Santa-Emma et al39 evaluated acute palliative
care service (APCS). The main findings were that
56% of patients were transferred to the APCS and
that the most common symptom was dyspnea (53%).
Brumley et al40 investigated whether an in-home
palliative care intervention had an impact on patient
satisfaction, reduced medical care costs, and/or
increased number of patients dying at home. In
summary, the results showed that patients in the
intervention group reported greater satisfaction with
care and were more likely to die at home compared
with the controls.
Rabow et al41 evaluated an outpatient palliative
medicine consultation. The patients were provided
with an interdisciplinary palliative care program,
including physician consultation, case management,
support, chaplaincy consultation, and artistic expression. The comprehensive care team (CCT) brought
about a reduction in dyspnea and anxiety, as well as
greater spiritual wellbeing, although no improvement
in terms of pain or depression was reported.
Discussion
The present literature review resulted in 29 articles.
However, most studies came from the USA, which
implies the need for caution when interpreting the
results. The cultural context differs from that of
Europe, and even European countries differ from
each other in terms of culture. This finding underlines the need for studies carried out in other cultural and geographical settings. When discussing
ease and relief in the context of palliative care, the
focus should not only be on physical pain but also on
the additional dimensions of suffering, which differ
in line with culture.42 Thus, it is important to investigate the meaning of suffering in different cultures.
Although much has been done to develop palliative
care practice, problems still remain. One main difficulty
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336
American Journal of Hospice & Palliative Medicine® / Vol. 25, No. 4, August/September 2008
relates to scope: who should have access to palliative
care? New research published by The International
Observatory on End of Life Care (IOELC) at Lancaster
University43 has found that in 78 countries (234 countries were included in their review), no palliative care
activity was available, and around half of the included
countries had established one or more palliative care
services. These findings point to the need for further indepth research. From an ethical perspective, this is also
a question of social justice.
In the present article, a crucial question is the
access of old people to palliative care. Empirical studies are needed to investigate the extent to which old
people have access to palliative care, and normative
problems should also be addressed. For example, is
there any reason why old people should not have
access to palliative care? Few studies focused on the
very old people, that is, individuals at the age of 80 and
above. For most individuals, the life span between 65
and 80 to 90 will include different phases. For example, at 65 to 70 years, an individual can still be productive and alert, whereas the years from 70 to 90 may
be filled with experiences of becoming more and more
dependent on the health care system, as well as on
close family members and on others who are significant. However, with regard to social justice, palliative
care for everybody who suffers from a terminal disease
is a goal worth striving for.44 Therefore, more studies
are required on the need and preferences of very old
people. Jerant et al29 described a palliative care model
for old people, the TLC (Time and Team oriented,
Longitudinal, and Collaborative and Comprehensive)
model. The model comprises 3 components: (a) palliative care must be timely to avoid unnecessary suffering, as well as team-oriented where trained nurses
play a central role, (b) it should be longitudinal with a
balance of palliative and curative measures, and (c)
the care should be collaborative and comprehensive,
with attention to existential issues.
Family members and other close ones play a central role in end-of-life care. In a doctoral dissertation
by Andersson,1 the author points out that the responsibility for the patient and the need for professional
support were the main issues for the family members
of the old people. Problems related to family relationships have only been studied to a limited extent.
However, the notion of the family as a problematic
unit is highlighted in a study by Coleen Fisher.45 The
author states that we should be aware of the problem
of abusive family relationships. This issue needs to be
identified if the goal of holistic care is to be obtained.
Another problem concerning informal caregivers of
terminally ill patients was pointed out by Harding and
Higginson46 who showed that carers often see their
role as a duty and lack self-identity, which means that
they are highly ambivalent. Kissane et al47 described
the family grief therapy model, which could serve as a
tool in helping families to cope with their grief and
improve their functioning.
Some of the articles presented in the Result section deal with questions concerning how palliative
care could be better organized. The palliative care
consultation services model is intended to improve
the quality of end-of-life care. However, Han and
Arnold48 discussed patient abandonment as an unintended outcome of a palliative care service and suggested that the ethical problems raised by the
responsibility of the staff should be taken seriously.
Their article highlights questions related to a good
death for old people. Hanson et al49 have identified
3 factors that hinder a good death in a nursing
home: lack of training, lack of focus on rehabilitation, and lack of resources. Moreover, 3 themes
appeared important in the definition of a good
death: individualized care, good relationships with
the care team, and comprehensive advance care
planning. The findings of the study by Hanson et al49
confirm the results of the present study, that is,
many of the intervention studies aim to improve
end-of-life care of old people by focusing on team
work and care planning.
Another problem is that much research in this area
is based on empirical data with a study design, which
does not allow for any generalizations of the findings.
This in turn is associated with the palliative care context, which is problematic because of the extremely
vulnerable patients. Most of the palliative care
researches to date have focused on the identification
of patient and family needs, the gaps in the health
care system, and the need for staff education.
However, Morrison50 points out that the results of
most studies are limited because of the methodological weaknesses and underlines the importance of
comprehensive research, including robust, that is
reliable and valid, studies to evaluate the effect of
generalizable palliative care structures.
Conclusions
End-of-life care is a much debated topic. One reason
may be that, by its nature, it does not lend itself to
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End-of-Life Care for Old People / Bolmsjo
large randomized controlled studies; thus, questions
remain to be answered. In this article, gaps concerning scientific knowledge have been identified. More
knowledge is needed in the following areas: the endof-life care in geographical and cultural settings other
than the USA, old people’s needs and preferences concerning end-of-life care, and the effect of adjusted and
generalizable palliative care models.
Acknowledgments
I want to express my gratitude to Rigmor Fransson, librarian, the Vardal Institute, for valuable help. Lund and
Gothenburg University, Sweden, for financial support.
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17. McMillan SC, Small BJ. Using the COPE intervention
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Case Study #5: Palliative Care
Directions:
Read the assigned chapters in the course textbooks (for the week’s covered by
this case study). Read the following information (statement and scenario).
Answer the questions at the end of the Scenario for P.C. using your textbooks,
the supplemental readings and other sources that you find to support your
statements. This case study should use the APA guidelines (title page (with
author notes), body (with your specific headings/subheadings),
citations/references, and graphs/tables/charts as appropriate). Please spell and
grammar check your submission prior to submitting via Blackboard –
Communications - Course Messages. No other forms of submission will be
accepted or graded.
Older Adults do not often want to think about their own or a loved ones’ demise. Even
when they are losing close friends and relatives, and despite their own failing health
status, there is often a lack of communication or shared decision making (Evans et al.,
2012). Health care providers struggle with the appropriate time to discuss end of life
issues due to not wanting to give up hope, while often patients would prefer to die rather
than prolong their suffering (Haifiz, 2013). In preparation for their final days, many will
complete estate planning, advance directives, living wills and medical power of attorney
documents, long before they are needed (National Caregivers Library, 2016). As health
fails, and no treatments are possible for a cure, Older Adults find coping mechanisms
for coming to terms with their end of life issues (Morrow, 2016, Feb 25). Often the
discussion includes palliative care options versus hospice care (WebMD, “What is
Palliative Care?,2016). Some Older Adults in severe, chronic pain, may prefer not to
wait and increasingly ask for healthcare provider assisted suicides which allow them to
leave on their terms (California State University/Institute for Palliative Care, 2015).
References
California State University/Institute for Palliative Care. (2015). Assisted-suicide Debate.
Retrieved from https://csupalliativecare.org/assisted-suicide/
Evans et al. (2012). Older patients’ attitudes towards and experiences of patientphysician end-of-life communication: a secondary analysis of interviews from
British, Dutch and Belgian patients. Retrieved from doi: 10.1186/1472-684X-1124
Haifiz, Y. (2013, Nov 21). American Attitudes towards Death: 12 Facts from New Pew
Research Center Survey. Retrieved from
http://www.huffingtonpost.com/2013/11/21/death-america-pewresearch_n_4312321.html
Morrow, A. (2016, Feb 25). Nearing Death Awareness: A Dying Persons Awareness
that Death is Near. Retrieved from
http://dying.about.com/od/thedyingprocess/a/death_awareness.htm
National Caregivers Library. (2016). Legal Matters. Retrieved from
http://www.caregiverslibrary.org/caregivers-resources/grp-legal-matters.aspx
WebMD. (2016). What is Palliative Care? Retrieved from
http://www.webmd.com/palliative-care/palliative-care-mr
Scenario
•
P.C. is an 97 year old female who has the following health conditions:
o Diabetes – Type II (diagnosed when she was 85 years old)
o Hypertension (aka High Blood Pressure) (diagnosed at 65 years old)
o End Stage Renal Disease (diagnosed when she was 90 years old); P.C.
was not eligible for a kidney transplant due to her age.
o Myocardial Infarction (heart attack) (95 years old). Has a Do Not
Resuscitate (DNR) standing order.
•
The following medications have been prescribed:
o Furosemide – 20 mg – 1x per day – Refill 1x per month
o Lisinopril - 10 mg - 1x per day – Refill 1x per month
o Losartan – 50 mg – 1x per day – Refill 1x per month
o Metformin HCL – 250 mg – twice a day – Refill 1x per month
o Dialysis every other day (Monday through Friday). Monitored closely on
the weekends.
•
P.C. is living in an assisted living facility where she has around the clock nursing
care and only 5 other residents. Her kidney dialysis is done at the assisted living
facility and she is not required to travel for treatment.
•
P.C. has Medicare, a Medigap and Long-term care for her insurances.
•
P.C. is overweight due to fluid retention related to the ESRD. (150 lbs. for 5’3”)
Questions for Case Study
1. What concerns do you have for P.C. regarding palliative care? (Note:
Explain what factors would be of concern regarding P.C.’s health status.)
2. What individuals/agencies should be involved in addressing these
concerns? (Note: Who should be included in the discussion or be
consulted regarding palliative care?)
3. How would you develop an intervention/care strategy for P.C.’s palliative
care decisions? (Note: Steps and documents necessary prepare for P.C.’s
end of life issues).
4. What can P.C. do to prepare for palliative care? (Note: What physical or
behavioral changes may be necessary to prepare P.C. for palliative care
issues? Ex: Legal, Spiritual, Emotional, etc.)
5. What other agencies should be involved in P.C.’s palliative care decisions?
(Note: Think about what types of agencies and methods – palliative care
versus hospice care are available.)
6. What processes or procedures are available to address P.C.’s concerns
regarding palliative care and end of life issues? (Note: Physician Assisted
Suicides, Living Wills, Medical Power of Attorney, Wills, Do Not Resuscitate
Orders (DNRs), Estate Planning, etc.)
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Turnitin Report
Formatting
Title Page
Citation
Outline
