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Aims: Palliative care integration improves quality of life among patients with lung cancer and their families. Despite these benefits, significant barriers persist and patients do not receive timely integration. This study sought to identify facilitators of and barriers to integration in lung cancer care. Materials & methods: Semistructured qualitative interviews were conducted with palliative care and lung cancer clinicians and analyzed using traditional content analysis. 23 clinicians were interviewed from geographically dispersed hospitals within a national healthcare system. Results: Palliative care integration improved over time, enhanced by several facilitators stratified at four levels (patient/clinician/hospital/organization). Most important among these was multidisciplinary care delivered in outpatient settings, fostering trust and relationships among clinicians which were pivotal to successful integration. Workforce shortages and limited use of primary palliative care among lung cancer clinicians need to be addressed for continued growth in the field. Conclusion: Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.
Palliative care is a form of supportive care for patients with a serious illness that improves quality of life among patients with lung cancer and their families. Unfortunately, many patients do not receive this care until they are near the end of life. This study sought to explore clinicians' perspectives regarding ways to enhance the use of palliative care among patients with lung cancer. Using interviews of clinicians from geographically dispersed hospitals within a national healthcare system, the authors explored reasons and potential solutions to improve palliative care delivery. One of the most important factors in enhancing palliative care use was fostering trust and relationships among palliative care and lung cancer clinicians. Workforce shortages also need to be addressed for continued growth in the field of palliative care. Relationships among clinicians are crucial to successful palliative care integration in lung cancer care.
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Neoplasias Pulmonares , Cuidados Paliativos , Humanos , Calidad de Vida , Neoplasias Pulmonares/terapia , Investigación CualitativaRESUMEN
INTRODUCTION: We developed Teachable Moment to Opt-Out of Tobacco (TeaM OUT) as a tobacco treatment intervention based on a foundation of a theoretical model of teachable moments, "naturally occurring life transitions or health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors". The TeaM OUT intervention combines a teachable moment for patients with newly detected incidental pulmonary nodules with a proactive interactive voice response (IVR) system to increase connections to evidence-based tobacco treatment interventions. METHODS: We will perform a convergent, nested observational mixed-methods study utilizing both randomized trial and observational methods to test the effectiveness and generalizability of the TeaM OUT intervention through three aims. AIM 1: Among patients recently diagnosed with a pulmonary nodule, we will utilize a pragmatic, stepped wedge randomized controlled design to evaluate the effectiveness of a proactive, teachable moment-based, tobacco treatment outreach intervention (TeaM OUT) on increasing engagement with tobacco treatment resources compared to Enhanced Usual Care. AIM 2: Using a longitudinal observational design, we will evaluate the association of receipt of the TeaM OUT intervention with seven-day point abstinence prevalence and quit motivation compared to Enhanced Usual Care. AIM 3: Qualitatively elicit perspectives from key stakeholders to inform acceptability and utility, implementation barriers and facilitators, and scalability of the TeaM OUT intervention. DISCUSSION: We are hopeful that implementation of TeaM OUT will increase the number of patients who quit using cigarettes with subsequent improvements in their health.
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Cese del Hábito de Fumar , Productos de Tabaco , Tabaquismo , Humanos , Proyectos de Investigación , Cese del Hábito de Fumar/métodos , Nicotiana , Tabaquismo/terapiaRESUMEN
This pilot study explored the feasibility of providing integrated primary and psychiatric care in a primary care setting and compared preliminary outcomes to those from a traditional care model. The study population consisted of 23 patients who received integrated medical and psychiatric care in a primary care clinic and 23 comparison patients who received medical care in a primary care clinic and psychiatric care in a separate mental health clinic. This study suggests that integrated care can be provided to chronically mentally ill patients in a primary care setting and generate outcomes comparable to those of standard care.
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Prestación Integrada de Atención de Salud , Evaluación de Resultado en la Atención de Salud , Atención Primaria de Salud , Enfermería Psiquiátrica , Adulto , Femenino , Humanos , Masculino , Trastornos Mentales/terapia , Servicios de Salud Mental , Persona de Mediana Edad , Proyectos PilotoRESUMEN
BACKGROUND: When the Oregon Death with Dignity Act (ODDA) legalizing physician-assisted suicide was enacted into law in 1997, Oregon hospice clinicians were uncertain how involved they would be with patients who wanted this option. However, 86% of the 171 persons in Oregon who have died by lethal prescription were enrolled in hospice programmes. METHOD: A mailed questionnaire was sent to all hospice nurses and social workers in Oregon in 2001 (n=573) to assess their attitudes about legalized assisted suicide and interactions with patients concerning this issue. Responses from 306 nurses and 85 social workers are included in this report. FINDINGS: Almost two-thirds of respondents reported that at least one patient had discussed assisted suicide as a potential option in the past year. Social workers were generally more supportive of both the ODDA and of patients choosing assisted suicide compared to nurses. Twenty-two per cent of all respondents were not comfortable discussing assisted suicide with patients. Ninety-five per cent of both groups, however, favoured hospice policies that would allow a patient to choose assisted suicide while enrolled in hospice and allow hospice clinicians to continue to provide care. INTERPRETATIONS: Nurses and social workers in hospices and other settings can expect to encounter patient questions about physician-assisted suicide, whether legalized or not, and must be prepared to have these discussions. Most hospice professionals in Oregon do not believe that assisted suicide and hospice enrollment are mutually exclusive alternatives.
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Actitud del Personal de Salud , Actitud Frente a la Muerte , Personal de Enfermería/psicología , Servicio Social , Suicidio Asistido/psicología , Hospitales para Enfermos Terminales , Humanos , Relaciones Enfermero-Paciente , Oregon , Encuestas y CuestionariosRESUMEN
As the ethical debate about euthanasia and physician-assisted suicide (PAS) continues, one alternative that has been suggested is for the patient to voluntarily refuse all food and fluids (VRFF). The article describes the results of a study of hospice nurses' and social workers' attitudes towards VRFF and compares them with their attitudes towards PAS. In 2001, a questionnaire was posted to nurses and social workers who care for Oregon residents enrolled in hospice programmes to determine their attitudes towards PAS and VRFF. In general, hospice workers expressed support for patients who choose to hasten their death by VRFF; they were less supportive of PAS. The results from this study suggest that perceptions regarding VRFF are significantly different from those regarding PAS. These results may have important clinical implications for nurses and social workers involved in end-of-life care who encounter patients who wish to hasten their deaths.
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Actitud del Personal de Salud , Cuidados Paliativos al Final de la Vida , Personal de Enfermería , Derecho a Morir , Servicio Social , Adulto , Anciano , Anciano de 80 o más Años , Actitud Frente a la Muerte , Eutanasia Pasiva/ética , Eutanasia Pasiva/legislación & jurisprudencia , Eutanasia Pasiva/psicología , Conducta Alimentaria/ética , Conducta Alimentaria/psicología , Femenino , Servicios de Atención de Salud a Domicilio/ética , Cuidados Paliativos al Final de la Vida/ética , Cuidados Paliativos al Final de la Vida/legislación & jurisprudencia , Cuidados Paliativos al Final de la Vida/psicología , Humanos , Masculino , Persona de Mediana Edad , Investigación Metodológica en Enfermería , Personal de Enfermería/ética , Personal de Enfermería/psicología , Oregon , Derecho a Morir/ética , Derecho a Morir/legislación & jurisprudencia , Servicio Social/ética , Encuestas y Cuestionarios , Negativa del Paciente al Tratamiento/ética , Negativa del Paciente al Tratamiento/legislación & jurisprudencia , Negativa del Paciente al Tratamiento/psicologíaRESUMEN
BACKGROUND: Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice. METHODS: We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results. RESULTS: Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. On the basis of the hospice nurses' reports, the patients who stopped eating and drinking were older than 55 patients who died by physician-assisted suicide (74 vs. 64 years of age, P<0.001), less likely to want to control the circumstances of their death (P<0.001), and less likely to be evaluated by a mental health professional (9 percent vs. 45 percent, P<0.001). CONCLUSIONS: On the basis of reports by nurses, patients in hospice care who voluntarily choose to refuse food and fluids are elderly, no longer find meaning in living, and usually die a "good" death within two weeks after stopping food and fluids.
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Ingestión de Líquidos , Ayuno , Negativa del Paciente al Tratamiento/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Actitud Frente a la Muerte , Cuidadores , Muerte , Deshidratación , Familia/psicología , Femenino , Hospitales para Enfermos Terminales , Humanos , Masculino , Persona de Mediana Edad , Personal de Enfermería , Oregon , Suicidio Asistido/estadística & datos numéricos , Encuestas y Cuestionarios , Negativa del Paciente al Tratamiento/psicologíaRESUMEN
BACKGROUND: The 1997 enactment of the Oregon Death with Dignity Act intensified interest in improving physician education and skills in caring for patients at the end of life. OBJECTIVE: To obtain hospice nurse and social workers' collateral ratings of efforts made by Oregon physicians to improve their palliative care skills over the previous 5 years. DESIGN: A descriptive survey of nurses and social workers from all 50 Oregon outpatient hospice agencies. MEASUREMENT AND RESULTS: Oregon hospice nurse (N=185) and social worker (N=52) respondents, who had worked in hospice for at least 5 years, rated changes they observed over the past 5 years in physicians' approach to caring for their hospice clients. Six characteristics, including willingness to refer patients to hospice, willingness to prescribe sufficient pain medications, knowledge about using pain medications in hospice patients, interest in caring for hospice patients, competence in caring for hospice patients, and fearfulness of prescribing sufficient opioid medications were evaluated. Positive changes were endorsed by the majority of respondents on all but the scale measuring fearfulness of prescribing opioid medications; on the latter, 47% of nurses rated doctors as less fearful, whereas 53% rated them as about the same or more fearful than they were 5 years earlier. CONCLUSIONS: Most respondents rated Oregon physicians as showing improvements in knowledge and willingness to refer and care for hospice patients.
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Cuidados Paliativos al Final de la Vida , Cuidados Paliativos , Pautas de la Práctica en Medicina/tendencias , Derecho a Morir/legislación & jurisprudencia , Suicidio Asistido/legislación & jurisprudencia , Analgésicos Opioides/uso terapéutico , Actitud del Personal de Salud , Competencia Clínica , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Enfermería , Oregon , Dolor/tratamiento farmacológico , Servicio SocialRESUMEN
BACKGROUND: Oregon's 1997 Death with Dignity Act legalizes physician-assisted suicide. To date, information about patients who have requested this option has come from surveys of physicians. Although 78 percent of the 91 Oregonians who have died by assisted suicide were enrolled in hospice programs, there is little information about the experiences of hospice practitioners with these patients. METHODS: In 2001, we mailed a questionnaire to all hospice nurses and social workers in Oregon. RESULTS: Of 545 eligible hospice nurses and social workers, 397 (73 percent) returned the survey, including 71 percent of nurses and 78 percent of social workers. Since November 1997, 179 of the respondents (45 percent) had cared for a patient who requested assistance with suicide. Hospice nurses reported on 82 patients who had received prescriptions for lethal medication. Ninety-eight percent of the nurses had discussed the request with a coworker, and 77 percent of the requests had been presented at a hospice interdisciplinary conference on patient care. A very important reason for the request was to control the circumstances of death. The least important reasons included depression, lack of social support, and fear of being a financial drain on family members. Although the patients were concerned about burdening others, only 11 percent of hospice nurses rated their family caregivers as more burdened than family caregivers for other hospice patients. CONCLUSIONS: Since assisted suicide was legalized in Oregon, many hospice nurses and social workers have provided care for a patient who requested assistance with suicide. They rated desire for control as a very important reason for these requests.