Yes / The role of non-medical prescribers working in palliative care has been expanding in recent years and prescribers report improvements in patient care, patient safety, better use of health professionals’ skills and more flexible team working. Despite this, there is a lack of empirical evidence to demonstrate its clinical and economic impact, limiting our understanding of the future role of non-medical prescribers within a healthcare system serving an increasing number of people with palliative care needs. We developed a unique methodology to establish the level of non-medical prescribers’ activity in palliative care across England and consider the likely overall contribution these prescribers are making at a national level in this context in relation to medical prescribing. All prescriptions for 10 core palliative care drugs prescribed by general practitioners, nurses and pharmacists in England and dispensed in the community between April 2011 and April 2015 were extracted from the Prescribing Analysis Cost Tool system. The data were broken down by prescriber and basic descriptive analysis of prescription frequencies by opioid, non-opioids and total prescriptions by year were undertaken. To evaluate the yearly growth of non-medical prescribers, the total number of prescriptions was compared by year for each prescribing group. Non-medical prescribers issued prescriptions rose by 28% per year compared to 9% in those issued by medical prescribers. Despite this, the annual growth in non-medical prescribers prescriptions was less than 1% a year in relation to total community palliative care prescribing activity in England. Impact on medical prescribing is therefore minimal.

Dame Cicely Saunders created the hospice movement to be a voice for the voiceless. Those needing palliative care needed someone to speak for them and ensure they received the care they needed and deserved. Today, more than forty years later, the voice of the patient and family are in danger of being lost. This research aimed to discover what patients and their families thought were the most important priorities in palliative care. If hospices, and any other facility that cares for the dying, are to give the care that patients and their families need then the research in this thesis shows benefit to those patients and families if asked to identify what are their needs. If palliative care is to be truly holistic we need to find out from patients, and from their families, what they believe is important. Using purposeful sampling, five patients and five family members were recruited from a hospice in-patient unit. In-depth interviews with open-ended questions were conducted with participants who were asked to share what had affected their care, or their relative’s care, while admitted to the hospice. These interviews were recorded and transcribed in a qualitative descriptive study to identify and analyse what these participants described as the ‘important thing’ in palliative care. Specific, tangible detail was sought in order to define the ‘essence’ of palliative care as determined by those receiving it. Thematic analysis revealed four key themes and associated sub-themes relating to: the people who work in a hospice; the environment; philosophy and holistic care. This research enables those caring for the dying in any context, to use the information shared by these individuals as guidance to enhance the care they offer to a dying person so that their final days may be more tolerable, even perhaps pleasurable: to help them ‘live until they die’.

No / Sheila Payne and colleagues examine the differences and similarities in end-of-life care provided in different countries which, while broadly based on the same models, varies according to resources, cultural attitudes and public health policies This article introduces palliative care and palliative care nursing. It goes on to consider models of palliative care delivery and provide a more detailed account of the three elements of palliative care nursing–working directly with patients and families, working with other health and social care professionals to network and co-ordinate services, and working at an organisational level to plan, develop and manage service provision in local, regional and national settings. It concludes by detailing the challenges for palliative care nursing and outlines a possible way ahead.

No / This article provides an academic and professional context for the articles written for this special issue. It discusses 4 broad questions often asked about the public health approach to palliative care: what is the evidence for the effectiveness of the approach?; will this approach embedded inside palliative care services deliver the kinds of social changes needed to address the social epidemiology of living with life limiting illness, long term caregiving and grief and bereavement?; Is recent interest in this approach simply all about cost-savings for governments?; and will an emphasis on health promotion and community development subtract from efforts to increase or maintain clinical supports at the end of life?

Purpose: Examine outpatient providers' perceptions of palliative care education in increasing their understanding, knowledge of resources, and intent to refer. Research questions/goals: 1) Increase provider understanding about palliative care and the benefits that patients can receive as a result of early referral; 2) Increase provider knowledge of palliative care facilities and resources within VHSO; 3) Increase provider intent to use the referral process for patients in need of palliative care. Setting: Veterans Healthcare System of the Ozarks, Fayetteville, Arkansas. Participants: 14 outpatient providers within VHSO; 8 MDs, 4 NPs, and 2 PAs. Methods: Descriptive research study consisting of an education session, discussion, and completion of a demographics form and evaluation questionnaire. Results: Questionnaire scores: Goal 1) 4.9 (SD=1.27)/6; Goal 2) 5.07 (SD=1.1)/6; Goal 3) 5.1 (SD=1.1)/6. Open ended question themes: 1) 21.4%: palliative care was an "umbrella"; 35.7%: early referral improves outcomes; 21.4%: treatment plan can include curative therapies; 2) 28.6%: open group discussion; 14.3%: training opportunities; 21.4%: multidisciplinary team approach. 3) 35.7%: screenshots of the referral process; 14.3%: individual comments for the care plan; 21.4%: open discussion regarding referrals. 4) 14.3%: more about how to accommodate homebound Veterans; 28.6%: more about telehealth opportunities; 21.4%: more information on communication tactics. Conclusions: There is a knowledge deficit among outpatient care providers in regards to palliative care. The providers found this education session informative, beneficial, and increased their intent to initiate palliative care referrals.

This population-based, retrospective descriptive analysis was conducted to study a cohort of decedents who died between January 2004 and December 2005 who were referred to the Regina QuAppelle Palliative Care Services (RQPCS). Demographics, diagnostic information and palliative service utilization were collected and analyzed. <p>The first step of the analysis included interviewing the program director and clinical consultant of the RQPCS. They provided the program vision and philosophy of the RQPCS as well as a comprehensive description of the program, including descriptions of the services offered and the staff of the palliative care team.<p>The second step of the research described in detail the demographics, palliative care service use and diagnostic background of the patients of the RQPCS. The variables of interest were age, gender, marital status, living arrangements, area of residence and diagnosis. Analysis also included determining which services the decedents accessed and how many of the services were used by each decedent. Timing of referrals and location of death were also analyzed. Frequencies and percentages were used to describe categorical variables. Means, median and range were used for continuous variables. <p>The third step of this thesis tested for associations between patient attributes and palliative care services utilization, timing of referral and location of death using chi-square analyses. <p>This research determined each of the patient characteristics under investigation to be associated with palliative care utilization. Similar findings were also evident in the literature. In particular, age, marital status, living arrangements, area of residence and diagnosis appeared to be significantly associated with accessing palliative care services. <p>When analyzing the associations between patient attributes and timing of referrals for the RQPCS, no significant results were found. Previous research indicated strong associations between marital status and diagnosis on the timing of referrals into hospice and palliative care programs.<p>Finally, there were two significant associations found between location of death and patient characteristics (gender and living arrangements). However, no clear conclusion could be reached on whether age, gender, marital status, living arrangement, area of residence or diagnosis had any effect on place of death in previous literature.

This population-based, retrospective descriptive analysis was conducted to study a cohort of decedents who died between January 2004 and December 2005 who were referred to the Regina QuAppelle Palliative Care Services (RQPCS). Demographics, diagnostic information and palliative service utilization were collected and analyzed. <p>The first step of the analysis included interviewing the program director and clinical consultant of the RQPCS. They provided the program vision and philosophy of the RQPCS as well as a comprehensive description of the program, including descriptions of the services offered and the staff of the palliative care team.<p>The second step of the research described in detail the demographics, palliative care service use and diagnostic background of the patients of the RQPCS. The variables of interest were age, gender, marital status, living arrangements, area of residence and diagnosis. Analysis also included determining which services the decedents accessed and how many of the services were used by each decedent. Timing of referrals and location of death were also analyzed. Frequencies and percentages were used to describe categorical variables. Means, median and range were used for continuous variables. <p>The third step of this thesis tested for associations between patient attributes and palliative care services utilization, timing of referral and location of death using chi-square analyses. <p>This research determined each of the patient characteristics under investigation to be associated with palliative care utilization. Similar findings were also evident in the literature. In particular, age, marital status, living arrangements, area of residence and diagnosis appeared to be significantly associated with accessing palliative care services. <p>When analyzing the associations between patient attributes and timing of referrals for the RQPCS, no significant results were found. Previous research indicated strong associations between marital status and diagnosis on the timing of referrals into hospice and palliative care programs.<p>Finally, there were two significant associations found between location of death and patient characteristics (gender and living arrangements). However, no clear conclusion could be reached on whether age, gender, marital status, living arrangement, area of residence or diagnosis had any effect on place of death in previous literature.

This dissertation explores the question “how does a person who is a cancer patient finds their way to being a dying person?” Through the lens of modernism (Giddens), discourse analysis (Foucault), and philosophical hermeneutics (Gadamer) the author examines how the institution of cancer control is constituted, and how the cancer patient is co-constructed by this system and people entering into it as people needing cancer treatment. Language is explored to uncover meanings and discourses which help shape this experience and self-narrative of the cancer patients who face leaving the cancer control system and do or do not find their way to palliative care systems. From this perspective the more solitary and less shaped experience of ‘unbecoming a cancer patient’ is explored for those cancer patients whose treatment has failed. The liminal space between the expert systems of cancer control and palliative care is what is revealed and problematized. What is explored is what this liminal space between these two systems is, and how people who find or lose themselves in this space at this time might be met, without succumbing to the modernist temptation to create yet another expert system to manage what is explored. What is at stake for people at this time is their own self-narrative going on, and it was found for some people in a liminal space this self-narrative faltered. It is revealed that nurses are best positioned epistemologically to support people at this time, and the question of where this support ought to happen is explored in terms of the ideological fit within current health system alignments. This work adds an important theoretical rendering of the term liminality and has important implications for person centred nursing care and health system redesign. / Graduate

Magister Scientiae (Physiotherapy) - MSc(Physio) / Palliative care is a vague and often confusing term used to describe a type of treatment model for chronic and life-threatening illnesses. WHO describes palliative care as an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness by: early identification, impeccable assessment, and treatment of pain, physical, psychosocial and spiritual. The aim of this study is to explore the perceptions of physiotherapists on palliative care in order to contribute to the understanding of the role of physiotherapists to the care of stroke patient in Zambia. The objectives of this study are to explore physiotherapists’ knowledge on palliative care, their perceptions on management of palliative care as well as explore its application in the rehabilitation of stroke patients; and lastly to make recommendations on guidelines based on the outcomes of this study. Method: an exploratory study, using qualitative design was used. Data collection techniques were in-depth individual interviews and FGDs that consisted of purposively sampling of physiotherapists working; at four selected hospitals and a rehabilitation centre in Lusaka. Audio recording from the interviews was transcribed verbatim for each session by an independent person. The study employed thematic content analysis for data analysis. The data was classified systematically by means of coding to identify key factors or issues such as concepts, categories, themes and the relationship between them. Results indicated that all participants in the current study perceived palliative care as a medical care for the chronic and terminal ill patient in whom stroke patient and family will benefit if it is applied in the early stages of the disease trajectory; as well as it does improve the patient and family quality of life. Furthermore they emphasized on multidisciplinary team and holistic approaches in order to achieve all its tenets. Conclusion: the study had succeeded in exploring the physiotherapists’ perceptions on palliative care and contributed to the understanding of the role of physiotherapy to the care of stroke patients in general.

Yes / We linked UK cancer registry data with the corresponding electronic primary care medical records of 6080 patients who died of cancer over a 7-year period in a large United Kingdom city. We extracted all prescriptions for analgesics issued to each patient in the linked cohort during the 12 months before death and analysed the extent and duration of strong opioid treatment with clinical and patient characteristics. Strong opioids were prescribed for 48% of patients in the last year of life. Median interval between first prescription of a strong opioid and death was 9 weeks (interquartile range 3-23). Strong opioid prescribing was not influenced by cancer type, duration of illness, or gender but was adversely influenced by older age. Compared with patients who died in a hospice, those who died in a hospital were 60% less likely to receive a strong opioid in primary care before admission (relative risk ratio 0.4, CI 0.3-0.5, P < 0.01). The study provides the first detailed analysis of the relatively late onset and short duration of strong opioid treatment in patients with cancer before death in a representative UK cohort. This pattern of prescribing does not match epidemiological data which point to earlier onset of pain. Although persistent undertreatment of cancer pain is well documented, this study suggests that strategies for earlier pain assessment and initiation of strong opioid treatment in community-based patients with cancer could help to improve pain outcomes. / National Institute for Health Research (NIHR) (RP-PG-0610-10114)