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BACKGROUND: Knowing someone with tuberculosis (TB) as a person, rather than defining them by their illness, is part of recognising their dignity and unique individuality, and a requirement for effective care. OBJECTIVE: An adaptation of the Patient Dignity Question (PDQ) was formalised for persons receiving treatment for active TB or latent tuberculous infection (LTBI), and its impact was evaluated for both the person and health care providers (HCPs). DESIGN: Individuals with active TB or LTBI receiving treatment in Winnipeg, MB, Canada, were asked the PDQ as part of routine care. Patients and HCPs were subsequently invited to evaluate the application of the PDQ. RESULTS: Of the 58 participants who responded to the PDQ, 97% felt both that it was important to ask about them as an individual, and that the PDQ should be asked of all patients, while 55% thought it made a difference to their care. Thirty-eight per cent of HCPs said they learned something new about their patient, and 31% said it influenced their sense of connectedness with and sense of empathy for patients, as well as their personal satisfaction in providing care. CONCLUSION: Formalising a dignity question as part of person-centred care provides a mechanism to create a respectful environment that is caring of the most marginalised who carry the burden of TB.

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BACKGROUND: Supportive-expressive group therapy has been reported to prolong survival among women with metastatic breast cancer. However, in recent studies, various psychosocial interventions have not prolonged survival. METHODS: In a multicenter trial, we randomly assigned 235 women with metastatic breast cancer who were expected to survive at least three months in a 2:1 ratio to an intervention group that participated in weekly supportive-expressive group therapy (158 women) or to a control group that received no such intervention (77 women). All the women received educational materials and any medical or psychosocial care that was deemed necessary. The primary outcome was survival; psychosocial function was assessed by self-reported questionnaires. RESULTS: Women assigned to supportive-expressive therapy had greater improvement in psychological symptoms and reported less pain (P=0.04) than women in the control group. A significant interaction of treatment-group assignment with base-line psychological score was found (P

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How do health care consumers, private sector organizations, professionals, and government agencies work toward ensuring quality end-of-life care? This challenge is by no means uniquely Canadian; our approach may thus have applications that extend well beyond our national borders. Raising the profile of palliative care in Canada has occurred on many fronts. Local, provincial, and national efforts in end-of-life care have long been underway. The Canadian Palliative Care Association has been particularly active, recently organizing various stakeholder groups to develop a strong national advocacy partnership for quality end-of-life care. Perhaps most distinctive has been the involvement and nationwide visibility of Canada's Senate. Their report, Quality End-of-Life Care: The Right of Every Canadian has seen Canadian palliative care gain unprecedented momentum. The federal government recently took the unprecedented step of creating a new office to represent palliative care within the federal cabinet. In Canada, it would appear that palliative care is an idea whose time has come.

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Clinical depression is a relatively common, and yet frequently overlooked, source of suffering among patients with cancer. All patients who face a life-threatening diagnosis such as cancer experience a normal albeit painful emotional reaction, but a substantial minority will become clinically depressed. This article reviews some basic information that oncology practitioners may find helpful in identifying patients at risk of experiencing a major depression. A brief overview of the epidemiology, diagnostic criteria, screening approaches, and special issues, such as depression in the elderly, high-risk populations, and suicide is also provided.

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The authors rated patients who were in advanced stages of cancer and in their final few weeks of life on their level of awareness of their medical prognosis (N = 200, mean age = 71.0 years). The authors measured prognostic awareness with a semistructured interview, dividing patients into those acknowledging No Awareness, Partial Awareness, and Complete Awareness. The authors also administered a semistructured interview for depressive disorders, along with an assessment of various demographic and social support measures. Nineteen patients (9.5%) denied awareness of both their terminal prognosis and foreshortened life expectancy. Thirty-four patients (17%) were placed in the partial awareness category, with the remaining 147 patients (73.5%) reporting complete awareness. Depression was nearly three times greater among patients who did not acknowledge their prognosis, as compared with those who demonstrated partial or complete acknowledgment (chi2 = 7.094), P = 0.029). In addition to depression, male patients, older patients, and those having "intense social contact" were associated with lower ratings of prognostic awareness. Dying patients differ in respect to their capacity to acknowledge their prognosis. Prognostic disavowal is most likely to arise in patients with underlying psychological distress and emotional turmoil.

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Depression remains a source of considerable suffering among dying older adults. Unfortunately, clinical depression commonly is overlooked in this vulnerable population and often goes untreated. An overview of diagnosing depression in older patients is presented. Various risk factors for depression in the palliative care setting are examined. The somatic therapies that are available for treatment consideration in older, depressed adults nearing death are reviewed.

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OBJECTIVE: To provide an overview of the palliative care literature salient to the psychiatric aspect of end-of-life care. METHOD: A literature review was conducted, targeting primarily empirical studies that addressed the following topics: 1) psychological issues pertaining to life-threatening conditions; 2) family issues in the context of palliative care; 3) psychological issues and challenges faced by end-of-life health care providers; and 4) psychiatric disorders, including depression, anxiety, and organic mental disorders, in people with terminal illness. RESULTS: There is a small but emerging literature that can guide psychiatrists in their role of providing care to dying patients. CONCLUSIONS: While psychiatry has made tremendous inroads toward providing care to patients throughout the life cycle, its presence is only just beginning to be felt in end-of-life care. Within the domain of palliative care, psychiatry has an expanded and important role to play.

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The BEST study, a multicenter randomized trial of group psychosocial support in metastatic breast cancer, had several unusual features that may have influenced recruitment, notably the group nature of the intervention and the need for close collaboration between medical and psychosocial investigators. The recruitment process was examined in light of these features. Establishment of study centers was facilitated by involvement of experienced medical investigators who had successfully collaborated in previous research projects. Systematic evaluation of potential subjects or direct recruitment by psychosocial investigators optimized recruitment; however, the group nature of the intervention prolonged recruitment. Overall, 652 women were approached and 237 (43.3% of those medically eligible) randomized. Using population-based estimates, 24.3% of women with metastatic breast cancer were assessed for the study and 8.7% randomized. A randomization ratio of 2:1 was required to form and maintain groups. Competing clinical trials were the greatest barrier to recruitment. Five lessons were learned during recruitment for this trial: (1) multicenter randomized trials of psychosocial interventions are feasible, even in very ill patients, (2) the use of a group intervention effectively increased the required sample size by 50%, (3) similarity of randomization rates suggests that generalizability of study results will probably be comparable to that of other randomized cancer trials, (4) multidisciplinary collaborations and involvement of experienced researchers facilitated enrollment, and (5) most challenges encountered in recruitment were similar to those seen in all clinical trials.

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BACKGROUND: Complex biomedical and psychosocial considerations figure prominently in the debate about euthanasia and assisted suicide. No study to date, however, has examined the extent to which a dying patient's will to live fluctuates as death approaches. METHODS: This study examined patients with cancer in palliative care. Will to live was measured twice daily throughout the hospital stay on a self-report 100 mm visual analogue scale. This scale was incorporated into the Edmonton symptom assessment system, a series of visual analogue scales measuring pain, nausea, shortness of breath, appetite, drowsiness, depression, sense of well-being, anxiety, and activity. Maximum and median fluctuations in will-to-live ratings, separated by 12 h, 24 h, 7 days, and 30 days, were calculated for each patient. FINDINGS: Of 585 patients admitted to palliative care during the study period (November, 1993, to May, 1995), 168 (29%; aged 31-89 years) met criteria of cognitive and physical fitness and agreed to take part. The pattern of median changes in will-to-live score suggested that will to live was stable (median changes <10 mm on 100 mm scale for all time intervals). By contrast, the average maximum changes in will-to-live score were substantial (12 h 33.1 mm, 24 h 35.8 mm, 7 days 48.8 mm, 30 days 68.0 mm). In a series of stepwise regression models carried out at 12 h, 24 h, and 1-4 weeks after admission, the four main predictor variables of will to live were depression, anxiety, shortness of breath, and sense of well-being, with the prominence of these variables changing over time. INTERPRETATION: Among dying patients, will to live shows substantial fluctuation, with the explanation for these changes shifting as death approaches.

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This study investigated the mediational hypothesis of hopelessness in predicting suicidal ideation in a group of 196 patients with advanced terminal cancer. Each patient underwent a semistructured interview to assess hopelessness and suicidal ideation, and also completed the Beck Depression Inventory (short form). Hopelessness was correlated more highly with suicidal ideation than was the level of depression. In multiple linear-regression analyses, hopelessness contributed uniquely to the prediction of suicidal ideation when the level of depression was controlled. For health care providers attending to the needs of dying patients, hopelessness appears to be an important clinical marker of suicidal ideation in this vulnerable patient population.

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The number of elderly Canadians is likely to double in 20 years, spurring a discussion of end-of-life care. We analyze the literature on the costs of this care and compare cost assessments of different models of palliative care. The cost of treatments for which there is little empirical support is factored into our cost-savings analysis and the methodological limits of cost-analysis studies are also discussed. We conclude that (a) depending upon the model of care, costs of end-of-life care are considerable, (b) costs of care become more expensive with distance from the home setting, (c) cost savings reported in palliative care settings may be a function of nearness to death; (d) family expenses on end-of-life care are substantial and are not factored into most cost-analysis studies, (e) a two-tiered system of palliative home care allows families with higher incomes to afford help in supporting home deaths, and (f) some treatments given to dying patients are costly while yielding little benefit.

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OBJECTIVE: This study compared the performance of four brief screening measures for depression in a group of terminally ill patients. The methods included 1) a single-item interview assessing depressed mood, 2) a two-item interview assessing depressed mood and loss of interest in activities, 3) a visual analog scale for depressed mood, and 4) the Beck Depression Inventory-Short Form. METHOD: Semistructured diagnostic interviews for depression were administered to 197 patients receiving palliative care for advanced cancer. The interview diagnoses served as the standards against which the screening performance of the four brief screening methods was assessed. RESULTS: Single-item interview screening correctly identified the eventual diagnostic outcome of every patient, substantially outperforming the questionnaire and visual analog measures. CONCLUSIONS: Brief screening measures for depression are important clinical tools for terminally ill patients. For diagnostic purposes, however, they do not approach the validity of a single-item interview that asks, in effect, "Are you depressed?"

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