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Effects of the hospital-based palliative care team on the care for cancer patients: An evaluation study
International Journal of Nursing Studies 51 (2014) 226–235
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Effects of the hospital-based palliative care team on the care for cancer patients: An evaluation study Chi-Yin Kao a, Wen-Yu Hu b,*, Tai-Yuan Chiu c, Ching-Yu Chen c a
Department of Nursing, University of Melbourne, Melbourne, Australia Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan c Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 October 2012 Received in revised form 7 May 2013 Accepted 14 May 2013
Background: The hospital-based palliative care team model has been implemented in most Western countries, but this model is new in Taiwan and there is little research to evaluate its outcomes. Objectives: The purpose of this study was to evaluate the effects of the hospital-based palliative care team on the care for cancer patients. Design: The design was a quasi-experimental study with a pretest–posttest design. Setting: A medical center, National Taiwan University Hospital in Taipei, Taiwan. Participants: Cancer patients were excluded after the hospital-based palliative care team visited if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24 h or would be discharged within 24 h, or could not communicate in Mandarin or Taiwanese. A sample of 60 patients who consulted the hospital-based palliative care team was recruited. Methods: Patients recruited to the study were divided to receive the usual care only (control group, n = 30) or the usual care plus visits from the hospital-based palliative care team (intervention group, n = 30). Data were collected using questionnaires including the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale at the initial assessment and one week later. Results: Comparison between groups revealed that the degree change for edema, fatigue, dry mouth, abdominal distention, and spiritual well-being in the intervention group showed significant improvement compared to the control group (p < 0.05). However, there was no difference between groups on measures of anxiety, depression and feeling of social support. Within group analysis showed patients’ pain score, dyspnea, and dysphagia improved in both groups (p < 0.05). In addition, the average degree of constipation and insomnia in the control group declined from baseline (p < 0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p < 0.05). Conclusion: The findings indicated the hospital-based palliative care team can improve the care for patients in relation to symptom management and spiritual well-being. The hospitalbased palliative care team is a good care model for patients and worth implementing in clinical practice in Taiwan. The results also provide a general understanding about how the hospital-based palliative care team works in Taiwanese culture. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Cancer patients Palliative care Hospital-based palliative care team
Abbreviation: HADS, Hospital Anxiety and Depression Scale. * Corresponding author at: Department of Nursing, College of Medicine, National Taiwan University, No. 1, Sec. 1, Ren-Ai Rd, Jhongjheng District, Taipei 100, Taiwan. Tel.: +886 2 2312 3456; fax: +886 2 2396 8390. E-mail address: [email protected] (W.-Y. Hu). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.05.008
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What is already known about the topic? Hospital-based palliative care teams have been implemented in acute hospital settings in most Western countries to provide a consultative service to clinicians with primary responsibility for the patient. Most studies from Western countries indicate that hospital-based palliative care teams can improve the provision of palliative care and reduce patient suffering and unmet needs. There is limited known about the impact of hospital-based palliative care teams in acute hospitals in East Asia. What this paper adds? Both the hospital-based palliative care team and acute hospital settings can improve patients’ pain control, dyspnea, and dysphagia in an East Asian setting. The hospital-based palliative care team can improve the care for patients, especially for symptom management and spiritual well-being, but feelings of emotional support and social support may be more difficult to affect. Communication and late referrals are barriers when attempting to improve the service quality of the hospital-based palliative care team in Taiwan. 1. Background Cancer has been the leading cause of death in Taiwan since 1982, suggesting an important role for inclusion of palliative care in cancer services. In 2004, deaths from cancer accounted for 27.2% (36,357) of all deaths in Taiwan, which increased by 5.3% from 1995 (DOH, 2006). Nevertheless, a national survey showed only 12% of patients with advanced cancer received palliative care (Kung, 2004). To help patients access palliative care at the end of life, the DOH in Taiwan adopted the hospitalbased palliative care team model in 2004. The aims of this model are to provide active total care to patients whose disease is not responsive to curative treatment, to offer an advisory service to acute clinicians and to embed the principles of hospice and palliative care within acute hospital settings (Bakitas et al., 2009; Oakley et al., 2005). Many studies indicate that hospital-based palliative care teams can be helpful to relieve cancer patients’ physical discomfort and provide psychological and social support (Groot et al., 2005). Furthermore, these teams help patients and their families to adjust to their impending death, support decisions about appropriate treatment and care, address factors impacting on quality of life and support preparation for death (Groot et al., 2005; Kirk and Collins, 2006). Moreover, the care provided by hospital-based palliative care teams may also increase patient satisfaction with medical teams, shorten the duration of hospitalization, and reduce medical costs (Cassel et al., 2010; Morrison et al., 2008; Rabow et al., 2004). A recent research paper by Temel et al. (2010) also reported early involvement of palliative care can lengthen survival.
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The literature also identifies limitations of hospitalbased palliative care teams. Morita et al. (2005b) and O’Mahony et al. (2005) pointed out that hospital-based palliative care teams had little impact on patients’ mood disorders such as depression. Morita et al. (2005a) and Rabow et al. (2003) also identified lack of communication between hospital-based palliative care teams and the acute hospital staff and late referrals from acute care staff as barriers to the effectiveness of hospital-based palliative care teams. These include situations where the health professionals in the acute hospital settings did not follow the advice provided by hospital-based palliative care teams and the fact that patients were likely to be near death by the time hospital-based palliative care teams were consulted. The DOH in Taiwan performed a pilot study to implement hospital-based palliative care teams in eight hospitals in 2004. This study found patient satisfaction with the teams was high with an average score of 4.87 where score 5 means very satisfied. In addition 90% of health professionals from the acute hospitals expressed that the hospital-based palliative care teams could help to deal with patients’ symptoms of discomfort, especially for pain control, support of psychosocial needs, and the delivery of palliative care knowledge and skills (Hsu et al., 2007). However, this study also showed that more than 50% cancer patients did not clearly understand their terminal condition when consulting hospital-based palliative care teams (Hsu et al., 2007). Truth telling is one of the clinical dilemmas posed by the family-oriented culture in Taiwan (Hsu et al., 2007; Hu and Yang, 2009; Kao et al., 2007). There are many challenges and myths, including inadequate training in communication skills for physicians and psychological barriers between family and medical staff (Hancock et al., 2007). For example, death is a taboo topic in Chinese culture. Truth telling signifies medical failure and imminent death, so family members are usually afraid that patients will be sad and lose hope even commit suicide after being informed of their serious condition (Hu et al., 2002). As a result, family members would request the health professionals to hold the bad news and this family-centered model of decision making is usually followed in the acute hospital settings (Hu and Yang, 2009; Yang et al., 2011). However, palliative care focuses on patients’ autonomy and respect for their free will. To resolve this clinical dilemma, part of the responsibility of hospital-based palliative care teams is to assist the medical staff in the acute hospital settings in communicating with the patient’s family and building mutual trust in order to inform patients about their terminal illness (Hsu et al., 2007). The success of the pilot study led to implementation of the hospital-based palliative care team model across Taiwan from 2005. The government program aims to increase the percentage of patients with advanced cancer receiving palliative care from 20% to 50% by 2015 (Kung, 2004). This study aimed to understand the effect of the hospital-based palliative care team on care for cancer patients in one hospital in Taiwan.
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2. Methods 2.1. Study design This project was a quasi-experimental study. A pretest– posttest design was used to evaluate the effects of the hospital-based palliative care team on care for cancer patients in a single hospital. Before data collection, this study had obtained an ethics approval from the National Taiwan University Hospital (No. 9561701031). 2.2. Sample size Sample size was calculated by the statistical software, PS-Power and Sample Size Calculation version 2. Previous studies demonstrated that hospital-based palliative care teams could significantly improve patients’ pain control so pain scores (0–10) were selected as the primary outcome. A 0.5 effect size was expected to ensure that the impact was clinically meaningful. At least 30 participants were needed for each group (alpha = 0.05; power = 0.8; effect size = 0.5). 2.3. Study subjects When patients with advanced cancer had palliative care needs in the acute hospital settings at the National Taiwan University Hospital in Taipei, Taiwan, their physicians would consult the hospital-based palliative care team. The reasons for patients to consult the hospital-based palliative care team included receiving active treatment but looking for symptom control, refusing curative treatment and looking for palliative care, and dealing with the issues of truth telling, death preparation, and emotional support. Patients who consulted the hospital-based palliative care team were screened for inclusion in the study from January 2006 to July 2006. Patients were included if they were more than 18 years old, were able to concentrate 15 min on the questionnaire assessment and having no psychological disorder. Patients were excluded if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24 h or would be discharged within 24 h based on the judgment of their physicians, or could not communicate in Mandarin or Taiwanese. A total of 214 patients were approached. Ninety-eight patients did not meet the inclusion criteria because of their severe physical condition such as coma or being likely to die within 24 h. Fifty-two subjects refused to participate. Therefore, only 64 patients consented to participate. 2.4. Interventions Patients would have two types of care choices after the hospital-based palliative care team visited initially: (1) staying in the acute hospital settings to receive the usual care only (control group), and (2) staying in the acute hospital settings to receive the usual care plus visits from the hospital-based palliative care team (intervention group). In consideration of ethical issues, the type of care was determined according to patients and their families’
wishes after the hospital-based palliative care team visited. If patients originally received the usual care but changed to usual care plus visits from the hospital-based palliative care team later, they would not be enrolled in this study for a second time. 2.4.1. Control group If patients decided to receive usual care only, the hospital-based palliative care team closed the consultation after the initial visit. Patients still stayed in the acute hospital settings and received the standard care. The ethos of acute hospital settings focuses on patients’ curative treatment, symptom management, and survival. In terms of truth telling, the family-centered model of decision making is followed. 2.4.2. Intervention group Patients opting for hospital-based palliative care team received regular visits from the team. The members in the hospital-based palliative care team, including fully hospice trained physicians, nurses, social workers, and chaplains, visit patients to assess their care needs and provide them with total care. The ethos of the hospital-based palliative care team service focuses on offering whole-person care, and patients’ comfort is the first priority. Hence, team members would provide the acute hospital settings with advice about medications based on ethical thinking; teach patients and their families skills to relieve uncomfortable physical symptoms; assist patients’ families with truth telling and preparing for death; and provide emotional support. In line with this, patients still received the standard care from the acute hospital settings. 2.5. Data collection and instruments Lists of potential participants were provided to one of the investigators (CY) by the hospital-based palliative care team after they obtained a patient’s referral. Following the initial visit of the hospital-based palliative care team, CY assessed the patient’s eligibility and, if eligible, would explain the study procedures and answer their questions. Following consent, baseline data were collected. The baseline assessment included demographic data along with a set of standardized questionnaires: the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale. The questionnaires were administered at baseline and one week later. 2.5.1. Symptom Distress Scale The Symptom Distress Scale evaluates 15 common physical symptoms among patients with cancer using a 5point scale of 0–4 to measure the degree of disturbance to the patient’s normal everyday functioning. The Symptom Distress Scale levels are as follows: 0, absence of symptoms; 1, present but not affecting daily life; 2, present and slightly affecting daily life; 3, present and moderately affecting daily life; 4, present and dominating daily life. The Symptom Distress Scale uses the following symptoms: pain, dyspnea, nausea/vomiting, constipation, dysphagia, malignant wound, ascites, edema, fatigue,
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insomnia, stool and urine incontinence, dry mouth, appetite loss, abdominal distention, and dizziness. This scale had been used to assess cancer patients’ symptom distress in the Taiwanese population and had acceptable reliability and validity (Hu, 2004; Kao et al., 2007). In this study, Cronbach’s alpha was 0.68 and the content validity index (CVI) was 0.93. 2.5.2. Hospital Anxiety and Depression Scale The Hospital Anxiety and Depression Scale (HADS) is contains 14 items and consists of two subscales: anxiety and depression. Each item is rated on a 4-point scale of 0–3, giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to show significant psychological morbidity, while scores of 8–10 represent borderline morbidity and scores of 0–7 are considered normal (Zigmond and Snaith, 1983). The reliability and validity of the Taiwanese version of HADS had been previously confirmed (Chen et al., 1999; Kao et al., 2007). In this study, Cronbach’s alpha was 0.83 and the CVI was 0.87. 2.5.3. Spiritual Well-Being Scale The Spiritual Well-Being Scale, containing 20 items rated on a 5-point scale of 1–5, was used to assess spiritual well-being in earlier studies (Kao et al., 2007; Yang, 2004). The Spiritual Well-Being Scale has three subscales evaluating the extent to which the patient positively experiences meaning and purpose in life, relationships with others and nature, and support from a supreme being (Yang, 2004). The higher the Spiritual Well-Being Scale score, the better the patient’s spiritual well-being. In this study, Cronbach’s alpha was 0.80 and the CVI was 0.94. 2.5.4. Social Support Scale The Social Support Scale is a modified version of the Social Supportive Behavior Scale (Barrera, 1981). It was applied to understand patients’ social support status in previous studies (Kao et al., 2007; Tseng, 1999) and contains 15 items consisting of three factors: essential support, affective support, and communicative and appraisal support. Each item is rated on a 4-point scale of 1–4, and the higher the score, the better the social support (Tseng, 1999). In this study Cronbach’s alpha was 0.91 and the CVI was 0.93. 2.6. Analysis methods SPSS for Windows Version 18 was used for the statistical analyses. Descriptive statistics, Student’s T tests, and nonparametric statistics were used for data analysis, and p < 0.05 denoted statistical significance. The onesample Kolmogorov–Smirmov test was used to examine the total number of physical symptoms, the subscales from the questionnaires at the initial assessment, and the changes in scores of pre- and post-testing from each questionnaire. The results indicated that the total number of physical symptoms and the scores of subscales were normally distributed. Therefore, the chi-squared test and independent-samples T test were used to check homogeneity. The results showed that there was no significant
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difference in demographic data and variables from the subscales between the groups in baseline assessment (Tables 1 and 2). Thus, paired-sample T tests for withingroup analysis were used for pre- and post-testing. Independent-sample T tests for normally distributed variables and the Mann–Whitney U tests for variables with abnormal distributions were used for between-group analyses. 3. Results 3.1. Demographic and baseline information Sixty-four patients enrolled and completed the initial survey; however, 4 patients died before they could complete the post-survey. As a result, only 30 patients stayed in each group and completed the questionnaires at both time points. Sixty-two percent of respondents were male, and the average age was 57.52 years old. More than half (55%) of patients had at least a high school education. Three quarters had religious beliefs, and 70% were married. The average time between the disease diagnosis date and the date of first contact with the hospital-based palliative care team was approximately 31.90 months (Table 1). 3.2. Effects of the hospital-based palliative care team 3.2.1. Within-group analysis for physical and psychological status The average number of physical symptoms and the degree of distress from pain, dyspnea, and dysphagia showed a significant decrease (p < 0.05) in both groups over time (Tables 3 and 4). Additionally, the average degree of distress from constipation and insomnia in the control group declined from baseline (p < 0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p < 0.05, Table 4). The subscale scores for anxiety and depression were also significantly lower than at baseline in the intervention group (p < 0.05, Table 3). 3.2.2. Within-group analysis for spiritual well-being and social support status The average scores for the Spiritual Well-Being Scale and its subscales, including meaning and purpose in life, improved significantly in the intervention group (p < 0.05). Additionally, both groups demonstrated significant improvement in average Social Support Scale scores, whereas the average scores of subscales for affective support and communicative and appraisal support showed significant improvement in the intervention group only (p < 0.05, Table 3). 3.2.3. Between-group analysis for physical and psychological status Comparison between groups revealed no difference on the average number of physical symptoms (p = 0.757, Table 3) after involvement of the hospital-based palliative care team. However, the degree change for edema, fatigue, dry mouth, and abdominal distention in the intervention
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Table 1 Demographic characteristics and homogeneity test. Control group (n = 30)
Variable
Intervention group (n = 30)
Total (N = 60)
n
%
n
%
n
%
Gender Male Female
17 13
56.7 43.3
20 10
66.7 33.3
37 23
61.7 38.3
Age, average SD (57.52 14.62) 260 years old >60 years old
17 13
56.7 43.3
17 13
56.7 43.3
34 26
56.7 43.3
Education level Junior high school or below High school or above
13 17
43.3 56.7
14 16
46.7 53.3
27 33
45.0 55.0
Religious belief No Yes
8 22
26.7 73.3
6 24
20.0 80.0
14 46
23.3 76.7
Marital status Single Married Widowed
1 25 4
3.3 83.3 13.3
6 17 7
20.0 56.7 23.3
7 42 11
11.7 70.0 18.3
Disease diagnosed period/month, mean SD (31.90 64.32) 24 months >24 months
18 12
60.0 40.0
20 10
66.7 33.3
38 22
63.3 36.7
group showed significant improvement compared with the control group (p < 0.05, Table 4). There was no significant difference in anxiety and depression between the groups (Table 3).
X2
P value
0.635
0.426
0.000
1.000
0.067
0.795
0.373
0.542
5.913
0.052
0.287
0.592
and appraisal support in the intervention group were significantly higher than the control group (p < 0.05, Table 3). 4. Discussion
3.2.4. Between-group analysis for spiritual well-being and social support status The changes in scores for the Spiritual Well-Being Scale in the intervention group were significantly higher than the control group (p < 0.05, Table 3), whereas there was no significant difference in its subscales between the groups (Table 3). There were no significant changes for the Social Support Scale and its subscales for essential support and affective support between the groups (Table 3). However, the changes in scores for the subscale for communicative
The results of this study reveal that the hospital-based palliative care team had a positive impact on symptom management and spiritual well-being. To our knowledge, this study is one of the first to compare the effects of the hospital-based palliative care team with standard care, particularly in the Asia-Pacific region. Because many countries are planning to implement palliative care widely for advanced cancer patients’ needs, this research project has potential applicability to other settings.
Table 2 Homogeneity test for subscales in the baseline. Variable
Control (n = 30) mean SD
Intervention (n = 30) mean SD
Total (N = 60) mean SD
t
P value
Symptom Distress Scale Total number of symptoms
7.13 2.24
8.40 3.38
7.77 2.91
1.711
0.093
HADS Anxiety Depression
5.87 4.97 8.17 4.27
6.30 4.67 9.40 5.16
6.08 4.79 8.78 4.73
0.348 1.009
0.729 0.317
Spiritual Well-Being Scale Meaning and purpose in life Relationships with others and nature Support of a supreme being
3.76 0.43 3.69 0.54 3.85 0.37 3.68 0.83
3.58 0.52 3.43 0.68 3.74 0.41 3.68 1.32
3.67 0.48 3.56 0.63 3.80 0.39 3.68 1.09
1.435 1.633 1.162 0.000
0.157 0.108 0.250 1.000
Social Supportive Scale Essential support Affective support Communicative and appraisal support
3.40 0.51 3.32 0.59 3.52 0.52 3.42 0.58
3.33 0.48 3.15 0.46 3.57 0.61 3.35 0.56
3.37 0.49 3.23 0.53 3.54 0.56 3.38 0.57
0.611 1.221 0.342 0.499
0.544 0.227 0.734 0.620
C.-Y. Kao et al. / International Journal of Nursing Studies 51 (2014) 226–235
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Table 3 Effects of the control group and the intervention group. Variable
Group
Pre
Post
Within group analysis
Mean
Mean
95% CI
Control Intervention
7.13 8.40
6.20 7.33
0.30 to 1.57 0.46 to 1.67
3.006 3.612
0.005 0.001
Control Intervention
5.87 6.30
4.87 4.93
0.53 to 2.53 0.50 to 2.24
1.338 3.217
0.191 0.003
Control Intervention
8.17 9.40
7.43 8.17
0.37 to 1.84 0.06 to 2.41
1.358 2.146
0.185 0.040
Control Intervention
3.76 3.58
3.75 3.68
0.06 to 0.07 0.17 to 0.02
0.102 2.656
0.919 0.013
Control Intervention
3.69 3.43
3.68 3.56
0.11 to 0.13 0.23 to 0.03
0.114 2.538
0.910 0.017
Control Intervention
3.85 3.74
3.84 3.80
0.05 to 0.07 0.17 to 0.04
0.414 1.287
0.682 0.208
Control Intervention
3.68 3.68
3.73 3.75
0.20 to 0.10 0.16 to 0.03
0.682 1.439
0.501 0.161
Control Intervention
3.40 3.33
3.46 3.42
0.11 to 0.15 to
2.188 3.661
0.037 0.001
Control Intervention
3.32 3.15
3.39 3.21
0.16 to 0.20 0.14 to 0.03
1.606 1.409
0.119 0.169
Control Intervention
3.52 3.57
3.55 3.67
0.10 to 0.03 0.17 to 0.03
1.072 3.026
0.293 0.005
Control Intervention
3.42 3.35
3.47 3.48
0.13 to 0.02 0.21 to 0.05
1.439 3.440
0.161 0.002
t
Between group analysis P value
Symptom Distress Scale Total number of symptoms
HADS Anxiety
Depression
Spiritual Well-Being Scale
Meaning and purpose in life
Relationships with others and nature
Support of a supreme being
Social Supportive Scale 0.00 0.04
Essential support
Affective support
Communicative and appraisal support
a
t or za
P value
t = 0.311
0.757
t = 0.427
0.671
t = 0.634
0.529
t=
2.061
0.044
t=
1.761
0.084
t=
1.320
0.192
t=
0.192
0.848
z=
1.888
0.059
z=
0.977
0.329
z=
1.273
0.203
z=
2.034
0.042
Independent-samples T test (normal distribution variables); Mann–Whitney U test (non-normal distribution variables) for between group analysis.
In this study, the hospital-based palliative care team improved the care for patients in relation to symptom management. The reason for this is the fact that nurses in the hospital-based palliative care team had undergone hospice-training programs and had become specialists (Morita et al., 2005). This underlines the purpose of the hospital-based palliative care team: to bring the principles of hospice and palliative care to acute hospital settings and provide better palliative care according to each patient’s suffering and individual care needs. Specifically, we found that nurses in the hospital-based palliative care team advised patients to get more exercise, taught them and their families to perform lymphatic massage, and used elastic compression garments to reduce edema, even though limb elevation for edema is the routine in acute hospital settings. These interventions are recommended by Erickson et al. (2001) as well. Nurses also encouraged patients to engage in exercise tolerably to decrease the sensation of fatigue which has been supported by Wagner and Cella (2004). They also suggested using lip cream for dry mouth, petroleum jelly to prevent dry lips, or mouth care with tea instead of
moistening the mouth with wet cotton swabs (McCann et al., 1994). If patients experienced abdominal distention, the nurses would inspect their bowel movement status. If patients had constipation or the frequency of their bowel movements decreased, nurses in the hospital-based palliative care team would investigate the underlying cause of constipation first and then would suggest the staff in the acute hospital settings add prokinetic agents or laxatives to patients’ drug regimens if needed (Larkin et al., 2008; Schiller, 2004). If patients’ elimination improved, their abdominal distention improved as well. To improve appetite loss, health professionals in the hospital-based palliative care team suggested patients eat smaller amounts of food and more times each day (Twycross et al., 2009). When patients complained of dizziness, the hospital-based palliative care team would assess the laboratory data and discuss the use of blood transfusions with staff in the acute hospital settings. These findings showed the hospital-based palliative care team could reduce the degree of distressing physical symptoms, which is consistent with the reports of previous studies (Bakitas et al., 2009; Hsu et al., 2007). Additionally, the
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Table 4 Changes of degree about physical symptoms (control, n = 30; intervention, n = 30). Variable
Group
Pre
Post
Within group analysis
Mean
Mean
95% CI
t
Between group analysis P value
1. Pain Control Intervention
2.87 2.95
2.17 1.77
0.27 to 1.12 0.72 to 1.65
3.425 5.266
0.002 0.000
Control Intervention
4.96 4.86
3.87 2.68
0.33 to 1.85 1.19 to 3.17
2.969 4.571
0.007 0.000
Control Intervention
2.25 2.45
1.50 1.65
0.22 to 1.28 0.33 to 1.27
3.000 3.559
0.009 0.002
Control Intervention
1.93 2.00
1.43 1.31
0.13 to 1.13 0.21 to 1.59
1.713 1.671
0.110 0.121
Control Intervention
1.55 2.37
0.55 1.94
0.15 to 1.85 0.21 to 1.08
0.622 1.447
0.026 0.168
Control Intervention
3.00 2.21
1.80 1.64
0.16 to 2.24 0.08 to 1.06
3.207 2.511
0.033 0.026
Control Intervention
4.00a 1.80
4.00a 1.20
0.08 to 1.28
2.449
0.070
Control Intervention
3.00 3.20
3.25 2.60
1.05 to 0.55 0.17 to 1.37
1.000 1.765
0.391 0.111
Control Intervention
2.09 2.44
1.91 1.50
0.22 to 0.59 0.37 to 1.50
1.000 3.529
0.341 0.003
Control Intervention
2.67 3.35
2.56 2.50
0.29 to 0.51 0.39 to 1.30
0.570 3.851
0.574 0.001
Control Intervention
2.50 2.29
1.72 1.94
0.11 to 1.45 0.48 to 1.18
2.439 0.899
0.026 0.382
Control Intervention
3.00 3.29
2.17 2.43
0.39 to 2.06 0.13 to 1.85
1.746 2.121
0.141 0.078
Control Intervention
2.52 2.96
2.30 2.12
0.15 to 0.59 0.37 to 1.33
1.226 3.627
0.233 0.001
Control Intervention
2.76 3.00
2.59 2.35
0.24 to 0.59 0.19 to 1.11
0.899 2.942
0.382 0.008
Control Intervention
2.22 3.24
1.78 1.81
0.01 to 0.90 0.86 to 2.00
2.046 5.246
0.057 0.000
Control Intervention
1.95 2.21
1.50 1.68
0.04 to 0.94 0.19 to 0.86
1.917 3.293
0.070 0.004
Pain score (0–10)
2. Dyspnea
3. Nausea/vomit
4. Constipation
5. Dysphagia
6. Oral ulcer
7.Ascites
8. Edema
9. Fatigue
10. Insomnia
11. Stool and urine incontinence
12. Dry mouth
13. Appetite loss
14. Abdominal distention
15. Dizziness
a
t
P value 0.937
0.353
1.262
0.212
0.976
0.333
0.253
0.801
0.247
0.806
0.628
0.532
0.226
0.822
1.516
0.139
2.443
0.019
2.580
0.012
1.208
0.232
0.417
0.678
2.274
0.027
1.987
0.052
2.796
0.007
0.626
0.534
SD is 0, cannot calculate t value.
hospital-based palliative care team members also assessed patients’ physical needs to reduce unnecessary artificial nutrition and hydration in order to relieve their edema, dyspnea, and anorexia (Ke et al., 2008). It is noteworthy that patients’ pain control, dyspnea, and dysphagia underwent significant improvements in both
groups. This implies that continued education for cancer symptom management plays a role enabling the health professionals in the acute hospital settings to assist their patients. This might also be the result of cross-contamination. The staff in the acute hospital settings had reviewed the notes from the hospital-based palliative care team, and they
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might also have witnessed the team members providing care to the patients. This could also assist the staff from acute hospital settings to care for patients who did not receive the care from the hospital-based palliative care team but had the same symptoms. Another reason is that these symptoms can be improved by drugs, so there was not a significant improvement from the hospital-based palliative care team compared with the acute hospital settings. We also found that patients’ spiritual well-being improved significantly after receiving care from the hospital-based palliative care team for one week, whereas their anxiety and depression status did not improve compared with the control group. The reason for the improvement of spiritual well-being is to assist in truth telling (Leung et al., 2006). After consulting the hospitalbased palliative care team, if patients wished to know their disease prognosis, the team members would assist the acute hospital settings in dealing with this issue. When patients are aware that death is forthcoming, they tend to refocus their hope on ‘‘being’’ rather than ‘‘doing,’’ to emphasize relationships with others and with God, and to explore beliefs regarding life after death. Therefore, awareness of terminal illness may become a turning point, at which people begin to deal with their spiritual needs and reach a better level of spiritual well-being (Leung et al., 2006). In line with this, their families will often be freed from the pressure of truth telling and be able to have a clear communication with the patients, helping them to make an appropriate decision for future treatments or care (Huang et al., 2008; Yang et al., 2011). Therefore, it becomes easier for patients and their families to communicate and prepare advance directives. Patients can feel less lonely in accepting their incurable status and face their death much more peacefully (Yang et al., 2011). However, patients in both groups underwent emotional suffering, such as involved in truth telling or facing death. Even though the hospital-based palliative care team had assisted them to deal with these issues, patients needed more time to adjust to these emotional impacts, and one week is not long enough to measure the effects. These findings were consistent with the research by Morita et al. (2005b) and O’Mahony et al. (2005). They pointed out that hospital-based palliative care teams did not improve patients’ emotional disturbances efficiently over a single week. Although our findings show the hospital-based palliative care team model provided effective care, there are nonetheless some sampling concerns that might influence our study results. These included: (1) patients or their families who refused the hospital-based palliative care team service were assigned to the control group; and (2) there was a higher proportion of unmarried patients who chose the hospital-based palliative care team service, even though there was no statistical significant difference. Considering patients’ desire to choose the different care models, we were unable to assess the impact of sample selection bias, which may have implications for the generalizability of the findings. As a result, we need to be careful in interpreting the effect of the hospital-based palliative care team in our study. Furthermore, there are some problems in the model in Taiwan. Due to the limited number of members of the
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hospital-based palliative care team, they usually visit each patient only two or three times per week and sometimes do not have enough communication with the acute hospital settings. As a result, the hospital-based palliative care team members often make up for the lack of conversations by writing notes in the medical chart. Sometimes, health professionals in the acute hospital settings may miss these messages and as a result do not manage patients’ problems in a timely way. These problems were also reported by Morita et al. (2005a) and Rabow et al. (2003). To resolve these problems, we suggest that hospital-based palliative care teams and acute hospital settings should use the same standard assessment tools, have regular meetings, and increase the frequency of patient visits. In this study, nearly 46% of patients consulted the hospital-based palliative care team for symptom management or death preparation (98/214) but were ineligible for the study requirements because they were in a coma or likely to die. This reflects the issue of late referrals, which is consistent with the reports by Morita et al. (2005a) and Rabow et al. (2003). In clinical practice, when patients were referred to the hospital-based palliative care team late, the time for families’ preparation for deterioration of the patients’ condition was insufficient and the hospitalbased palliative care team only could provide limited assistance. Therefore, early referral to the hospital-based palliative care team is recommended. Certain limitations in this study should be mentioned. First, patients were divided into two groups according to whether or not they wished to receive the care from the hospital-based palliative care team. Due to ethical and practical consideration, the patients in the study could not be randomly assigned to two groups. The study was therefore conducted as a quasi-experimental design. Since respect for autonomy remains the basic ethical principle in most countries, this study design can be justified. Second, a 1-week follow-up time was used to consider the patients’ condition. This might only reflect the short term issues in the care such as symptom management. However, more time may be needed to deal with patients’ needs involving emotional disturbances and social support. Third, there was no standard checklist to evaluate the quality of the hospital-based palliative care team at the beginning of this model’s implementation in Taiwan, so the study used a series of questionnaires to measure. As a result, a total of 60 patients were recruited from 214 consecutive subjects. The representativeness of end-of-life subjects and effects on the hospital-based palliative care team may be limited. The last point is that this study only applies to a hospital population with a small sample size, so the generalizability of the results may be a concern. Although there has been similar patient demographic data within hospitals with hospital-based palliative care teams in Taiwan, according to reports from DOH in Taiwan, there is always a possibility that institutions may have differed on other variables as well. Hence, further rigorous sampling strategies from multiple sites should be conducted to recruit larger samples. We also recommend the further studies could recruit at least 41 participants in each group in order to find a difference in pain level between groups. It is based
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on the pain score data in the study with a power of 80% and alpha level of 0.05. 5. Conclusion This was the first project to evaluate the effect of hospital-based palliative care teams on care for cancer patients in Taiwan. The findings show that hospital-based palliative care teams can improve care for advanced cancer patients, especially for symptom management and spiritual well-being. Even though there are still some problems to be overcome in the implementation of hospital-based palliative care teams in Taiwan, these results also provide a general understanding about the outcomes of the hospital-based palliative care team in Taiwanese culture. We found communication and late referrals are barriers when attempting to improve the service quality of the hospital-based palliative care team. Members of hospital-based palliative care teams and acute hospital staff are encouraged to have regular meetings to improve their communication and provide patients and their families with more efficient care, and early referral is recommended. In view of the small sample size and a 1-week follow-up period, it would be desirable to conduct additional studies using larger samples to explore long-term effects of the hospital-based palliative care team on the clinical practice. In conclusion, the hospital-based palliative care team is a good care model for patients, and its implementation in clinical practice should be continued. Conflict of interests None of the authors have any conflicts of interests with regards to this research. Funding None. Ethical approval Ethics committee from the National Taiwan University Hospital. Acknowledgements The authors thank the medical staff and the hospitalbased palliative care team members of National Taiwan University Hospital for their full support. References Bakitas, M., Lyons, K.D., Hegel, M.T., Balan, S., Brokaw, F.C., Seville, J., et al., 2009. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA 32 (7) 741–749. Barrera, M.J., 1981. Social support in the adjustment of pregnant adolescents: assessment issues. In: Gottlieb, B.H. (Ed.), Social Network and Social Support. Sage, London, pp. 69–96. Cassel, B.J., Kerr, K., Pantilat, S., Smith, T.J., 2010. Palliative care consultation and hospital length of stay. Journal of Palliative Medicine 13 (6) 761–767.
Chen, P.Y., Shin, L.J., Wang, J.S., Lai, Y.H., Chang, H.K., Chen, M.L., 1999. The impact of pain on the anxiety and depression of cancer patients. Formosa Journal of Medicine 3 (4) 273–382. Department of Health (DOH), Taiwan, 2006. 2004 statistics of causes of death. http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10118&class_no=440&level_no=4 (accessed 16.07.12). Erickson, V.S., Person, M.L., Ganz, P.A., Adams, J., Kahn, K.L., 2001. Arm edema in breast cancer patients. Journal of the National Cancer Institute 93 (2) 96–111. Groot, M.M., Vernooij-Dassen, M.J., Courtens, A.M., Kuin, A., van der Linden, B.A., van Zuylen, L., Crul, B.J., Grol, R.P., 2005. Requests from professional care providers for consultation with palliative care consultation teams. Supportive Care in Cancer 13 (11) 920–928. Hancock, K., Clayton, J.M., Paker, S.M., Walder, S., Butow, P.N., Carrick, S., et al., 2007. 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Palliative Medicine 22, 796–807. Leung, K.K., Chiu, T.T., Chen, C.Y., 2006. The influence of awareness of terminal condition on spiritual well-being in terminal cancer patients. Journal of Pain and Symptom Management 31 (5) 449–456. McCann, R.M., Hall, W.J., Groth-Juncker, A., 1994. Comfort care for terminal ill patients. Journal of the American Medical Association 272 (16) 1263–1266. Morita, T., Akechi, T., Ikenaga, M., Kizawa, Y., Mukaiyama, T., et al., 2005a. Late referrals to specialized palliative care service in Japan. Journal of Clinical Oncology 23 (12) 2637–2644. Morita, T., Fujimoto, K., Tei, Y., 2005b. Palliative care team: the first year audit in Japan. Journal of Pain and Symptom Manage 29, 458–465. Morrison, R.S., Penrod, J.D., Cassel, J.B., Caust-Ellenbogen, M., Litke, A., Spragens, L., et al., 2008. Cost saving associated with US hospital palliative care consultation programs. Archives of Internal Medicine 168 (16) 1783–1790. Oakley, C., Pennington, K., Mulford, P., 2005. Perceptions of the role of the hospital palliative care team. Nursing Times 101 (37) 38–42. O’Mahony, S., Blank, A.E., Zallman, L., Selwyn, P.A., 2005. The benefits of a hospital-based inpatient palliative care consultation service: preliminary outcome data. Journal of Palliative Medicine 8 (5) 1033–1039. Rabow, M.W., Dibble, S.L., Pantilat, S.Z., McPhee, S.J., 2004. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Archives of Internal Medicine 164 (1) 83–91. Rabow, M.W., Petersen, J., Schanche, K., Dibble, S.L., McPhee, S.J., 2003. The comprehensive care team: a description of a controlled trial of care at the beginning of the end of life. Journal of Palliative Medicine 6 (3) 489–499. Schiller, L.R., 2004. New and emerging treatment options for chronic constipation. Reviews in Gastroenterological Disorders 4 (Suppl. 2) S43–S51. 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Effects of the hospital-based palliative care team on the care for cancer patients: An evaluation study Chi-Yin Kao a, Wen-Yu Hu b,*, Tai-Yuan Chiu c, Ching-Yu Chen c a
Department of Nursing, University of Melbourne, Melbourne, Australia Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan c Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 October 2012 Received in revised form 7 May 2013 Accepted 14 May 2013
Background: The hospital-based palliative care team model has been implemented in most Western countries, but this model is new in Taiwan and there is little research to evaluate its outcomes. Objectives: The purpose of this study was to evaluate the effects of the hospital-based palliative care team on the care for cancer patients. Design: The design was a quasi-experimental study with a pretest–posttest design. Setting: A medical center, National Taiwan University Hospital in Taipei, Taiwan. Participants: Cancer patients were excluded after the hospital-based palliative care team visited if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24 h or would be discharged within 24 h, or could not communicate in Mandarin or Taiwanese. A sample of 60 patients who consulted the hospital-based palliative care team was recruited. Methods: Patients recruited to the study were divided to receive the usual care only (control group, n = 30) or the usual care plus visits from the hospital-based palliative care team (intervention group, n = 30). Data were collected using questionnaires including the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale at the initial assessment and one week later. Results: Comparison between groups revealed that the degree change for edema, fatigue, dry mouth, abdominal distention, and spiritual well-being in the intervention group showed significant improvement compared to the control group (p < 0.05). However, there was no difference between groups on measures of anxiety, depression and feeling of social support. Within group analysis showed patients’ pain score, dyspnea, and dysphagia improved in both groups (p < 0.05). In addition, the average degree of constipation and insomnia in the control group declined from baseline (p < 0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p < 0.05). Conclusion: The findings indicated the hospital-based palliative care team can improve the care for patients in relation to symptom management and spiritual well-being. The hospitalbased palliative care team is a good care model for patients and worth implementing in clinical practice in Taiwan. The results also provide a general understanding about how the hospital-based palliative care team works in Taiwanese culture. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Cancer patients Palliative care Hospital-based palliative care team
Abbreviation: HADS, Hospital Anxiety and Depression Scale. * Corresponding author at: Department of Nursing, College of Medicine, National Taiwan University, No. 1, Sec. 1, Ren-Ai Rd, Jhongjheng District, Taipei 100, Taiwan. Tel.: +886 2 2312 3456; fax: +886 2 2396 8390. E-mail address: [email protected] (W.-Y. Hu). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.05.008
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What is already known about the topic? Hospital-based palliative care teams have been implemented in acute hospital settings in most Western countries to provide a consultative service to clinicians with primary responsibility for the patient. Most studies from Western countries indicate that hospital-based palliative care teams can improve the provision of palliative care and reduce patient suffering and unmet needs. There is limited known about the impact of hospital-based palliative care teams in acute hospitals in East Asia. What this paper adds? Both the hospital-based palliative care team and acute hospital settings can improve patients’ pain control, dyspnea, and dysphagia in an East Asian setting. The hospital-based palliative care team can improve the care for patients, especially for symptom management and spiritual well-being, but feelings of emotional support and social support may be more difficult to affect. Communication and late referrals are barriers when attempting to improve the service quality of the hospital-based palliative care team in Taiwan. 1. Background Cancer has been the leading cause of death in Taiwan since 1982, suggesting an important role for inclusion of palliative care in cancer services. In 2004, deaths from cancer accounted for 27.2% (36,357) of all deaths in Taiwan, which increased by 5.3% from 1995 (DOH, 2006). Nevertheless, a national survey showed only 12% of patients with advanced cancer received palliative care (Kung, 2004). To help patients access palliative care at the end of life, the DOH in Taiwan adopted the hospitalbased palliative care team model in 2004. The aims of this model are to provide active total care to patients whose disease is not responsive to curative treatment, to offer an advisory service to acute clinicians and to embed the principles of hospice and palliative care within acute hospital settings (Bakitas et al., 2009; Oakley et al., 2005). Many studies indicate that hospital-based palliative care teams can be helpful to relieve cancer patients’ physical discomfort and provide psychological and social support (Groot et al., 2005). Furthermore, these teams help patients and their families to adjust to their impending death, support decisions about appropriate treatment and care, address factors impacting on quality of life and support preparation for death (Groot et al., 2005; Kirk and Collins, 2006). Moreover, the care provided by hospital-based palliative care teams may also increase patient satisfaction with medical teams, shorten the duration of hospitalization, and reduce medical costs (Cassel et al., 2010; Morrison et al., 2008; Rabow et al., 2004). A recent research paper by Temel et al. (2010) also reported early involvement of palliative care can lengthen survival.
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The literature also identifies limitations of hospitalbased palliative care teams. Morita et al. (2005b) and O’Mahony et al. (2005) pointed out that hospital-based palliative care teams had little impact on patients’ mood disorders such as depression. Morita et al. (2005a) and Rabow et al. (2003) also identified lack of communication between hospital-based palliative care teams and the acute hospital staff and late referrals from acute care staff as barriers to the effectiveness of hospital-based palliative care teams. These include situations where the health professionals in the acute hospital settings did not follow the advice provided by hospital-based palliative care teams and the fact that patients were likely to be near death by the time hospital-based palliative care teams were consulted. The DOH in Taiwan performed a pilot study to implement hospital-based palliative care teams in eight hospitals in 2004. This study found patient satisfaction with the teams was high with an average score of 4.87 where score 5 means very satisfied. In addition 90% of health professionals from the acute hospitals expressed that the hospital-based palliative care teams could help to deal with patients’ symptoms of discomfort, especially for pain control, support of psychosocial needs, and the delivery of palliative care knowledge and skills (Hsu et al., 2007). However, this study also showed that more than 50% cancer patients did not clearly understand their terminal condition when consulting hospital-based palliative care teams (Hsu et al., 2007). Truth telling is one of the clinical dilemmas posed by the family-oriented culture in Taiwan (Hsu et al., 2007; Hu and Yang, 2009; Kao et al., 2007). There are many challenges and myths, including inadequate training in communication skills for physicians and psychological barriers between family and medical staff (Hancock et al., 2007). For example, death is a taboo topic in Chinese culture. Truth telling signifies medical failure and imminent death, so family members are usually afraid that patients will be sad and lose hope even commit suicide after being informed of their serious condition (Hu et al., 2002). As a result, family members would request the health professionals to hold the bad news and this family-centered model of decision making is usually followed in the acute hospital settings (Hu and Yang, 2009; Yang et al., 2011). However, palliative care focuses on patients’ autonomy and respect for their free will. To resolve this clinical dilemma, part of the responsibility of hospital-based palliative care teams is to assist the medical staff in the acute hospital settings in communicating with the patient’s family and building mutual trust in order to inform patients about their terminal illness (Hsu et al., 2007). The success of the pilot study led to implementation of the hospital-based palliative care team model across Taiwan from 2005. The government program aims to increase the percentage of patients with advanced cancer receiving palliative care from 20% to 50% by 2015 (Kung, 2004). This study aimed to understand the effect of the hospital-based palliative care team on care for cancer patients in one hospital in Taiwan.
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2. Methods 2.1. Study design This project was a quasi-experimental study. A pretest– posttest design was used to evaluate the effects of the hospital-based palliative care team on care for cancer patients in a single hospital. Before data collection, this study had obtained an ethics approval from the National Taiwan University Hospital (No. 9561701031). 2.2. Sample size Sample size was calculated by the statistical software, PS-Power and Sample Size Calculation version 2. Previous studies demonstrated that hospital-based palliative care teams could significantly improve patients’ pain control so pain scores (0–10) were selected as the primary outcome. A 0.5 effect size was expected to ensure that the impact was clinically meaningful. At least 30 participants were needed for each group (alpha = 0.05; power = 0.8; effect size = 0.5). 2.3. Study subjects When patients with advanced cancer had palliative care needs in the acute hospital settings at the National Taiwan University Hospital in Taipei, Taiwan, their physicians would consult the hospital-based palliative care team. The reasons for patients to consult the hospital-based palliative care team included receiving active treatment but looking for symptom control, refusing curative treatment and looking for palliative care, and dealing with the issues of truth telling, death preparation, and emotional support. Patients who consulted the hospital-based palliative care team were screened for inclusion in the study from January 2006 to July 2006. Patients were included if they were more than 18 years old, were able to concentrate 15 min on the questionnaire assessment and having no psychological disorder. Patients were excluded if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24 h or would be discharged within 24 h based on the judgment of their physicians, or could not communicate in Mandarin or Taiwanese. A total of 214 patients were approached. Ninety-eight patients did not meet the inclusion criteria because of their severe physical condition such as coma or being likely to die within 24 h. Fifty-two subjects refused to participate. Therefore, only 64 patients consented to participate. 2.4. Interventions Patients would have two types of care choices after the hospital-based palliative care team visited initially: (1) staying in the acute hospital settings to receive the usual care only (control group), and (2) staying in the acute hospital settings to receive the usual care plus visits from the hospital-based palliative care team (intervention group). In consideration of ethical issues, the type of care was determined according to patients and their families’
wishes after the hospital-based palliative care team visited. If patients originally received the usual care but changed to usual care plus visits from the hospital-based palliative care team later, they would not be enrolled in this study for a second time. 2.4.1. Control group If patients decided to receive usual care only, the hospital-based palliative care team closed the consultation after the initial visit. Patients still stayed in the acute hospital settings and received the standard care. The ethos of acute hospital settings focuses on patients’ curative treatment, symptom management, and survival. In terms of truth telling, the family-centered model of decision making is followed. 2.4.2. Intervention group Patients opting for hospital-based palliative care team received regular visits from the team. The members in the hospital-based palliative care team, including fully hospice trained physicians, nurses, social workers, and chaplains, visit patients to assess their care needs and provide them with total care. The ethos of the hospital-based palliative care team service focuses on offering whole-person care, and patients’ comfort is the first priority. Hence, team members would provide the acute hospital settings with advice about medications based on ethical thinking; teach patients and their families skills to relieve uncomfortable physical symptoms; assist patients’ families with truth telling and preparing for death; and provide emotional support. In line with this, patients still received the standard care from the acute hospital settings. 2.5. Data collection and instruments Lists of potential participants were provided to one of the investigators (CY) by the hospital-based palliative care team after they obtained a patient’s referral. Following the initial visit of the hospital-based palliative care team, CY assessed the patient’s eligibility and, if eligible, would explain the study procedures and answer their questions. Following consent, baseline data were collected. The baseline assessment included demographic data along with a set of standardized questionnaires: the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale. The questionnaires were administered at baseline and one week later. 2.5.1. Symptom Distress Scale The Symptom Distress Scale evaluates 15 common physical symptoms among patients with cancer using a 5point scale of 0–4 to measure the degree of disturbance to the patient’s normal everyday functioning. The Symptom Distress Scale levels are as follows: 0, absence of symptoms; 1, present but not affecting daily life; 2, present and slightly affecting daily life; 3, present and moderately affecting daily life; 4, present and dominating daily life. The Symptom Distress Scale uses the following symptoms: pain, dyspnea, nausea/vomiting, constipation, dysphagia, malignant wound, ascites, edema, fatigue,
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insomnia, stool and urine incontinence, dry mouth, appetite loss, abdominal distention, and dizziness. This scale had been used to assess cancer patients’ symptom distress in the Taiwanese population and had acceptable reliability and validity (Hu, 2004; Kao et al., 2007). In this study, Cronbach’s alpha was 0.68 and the content validity index (CVI) was 0.93. 2.5.2. Hospital Anxiety and Depression Scale The Hospital Anxiety and Depression Scale (HADS) is contains 14 items and consists of two subscales: anxiety and depression. Each item is rated on a 4-point scale of 0–3, giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are considered to show significant psychological morbidity, while scores of 8–10 represent borderline morbidity and scores of 0–7 are considered normal (Zigmond and Snaith, 1983). The reliability and validity of the Taiwanese version of HADS had been previously confirmed (Chen et al., 1999; Kao et al., 2007). In this study, Cronbach’s alpha was 0.83 and the CVI was 0.87. 2.5.3. Spiritual Well-Being Scale The Spiritual Well-Being Scale, containing 20 items rated on a 5-point scale of 1–5, was used to assess spiritual well-being in earlier studies (Kao et al., 2007; Yang, 2004). The Spiritual Well-Being Scale has three subscales evaluating the extent to which the patient positively experiences meaning and purpose in life, relationships with others and nature, and support from a supreme being (Yang, 2004). The higher the Spiritual Well-Being Scale score, the better the patient’s spiritual well-being. In this study, Cronbach’s alpha was 0.80 and the CVI was 0.94. 2.5.4. Social Support Scale The Social Support Scale is a modified version of the Social Supportive Behavior Scale (Barrera, 1981). It was applied to understand patients’ social support status in previous studies (Kao et al., 2007; Tseng, 1999) and contains 15 items consisting of three factors: essential support, affective support, and communicative and appraisal support. Each item is rated on a 4-point scale of 1–4, and the higher the score, the better the social support (Tseng, 1999). In this study Cronbach’s alpha was 0.91 and the CVI was 0.93. 2.6. Analysis methods SPSS for Windows Version 18 was used for the statistical analyses. Descriptive statistics, Student’s T tests, and nonparametric statistics were used for data analysis, and p < 0.05 denoted statistical significance. The onesample Kolmogorov–Smirmov test was used to examine the total number of physical symptoms, the subscales from the questionnaires at the initial assessment, and the changes in scores of pre- and post-testing from each questionnaire. The results indicated that the total number of physical symptoms and the scores of subscales were normally distributed. Therefore, the chi-squared test and independent-samples T test were used to check homogeneity. The results showed that there was no significant
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difference in demographic data and variables from the subscales between the groups in baseline assessment (Tables 1 and 2). Thus, paired-sample T tests for withingroup analysis were used for pre- and post-testing. Independent-sample T tests for normally distributed variables and the Mann–Whitney U tests for variables with abnormal distributions were used for between-group analyses. 3. Results 3.1. Demographic and baseline information Sixty-four patients enrolled and completed the initial survey; however, 4 patients died before they could complete the post-survey. As a result, only 30 patients stayed in each group and completed the questionnaires at both time points. Sixty-two percent of respondents were male, and the average age was 57.52 years old. More than half (55%) of patients had at least a high school education. Three quarters had religious beliefs, and 70% were married. The average time between the disease diagnosis date and the date of first contact with the hospital-based palliative care team was approximately 31.90 months (Table 1). 3.2. Effects of the hospital-based palliative care team 3.2.1. Within-group analysis for physical and psychological status The average number of physical symptoms and the degree of distress from pain, dyspnea, and dysphagia showed a significant decrease (p < 0.05) in both groups over time (Tables 3 and 4). Additionally, the average degree of distress from constipation and insomnia in the control group declined from baseline (p < 0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p < 0.05, Table 4). The subscale scores for anxiety and depression were also significantly lower than at baseline in the intervention group (p < 0.05, Table 3). 3.2.2. Within-group analysis for spiritual well-being and social support status The average scores for the Spiritual Well-Being Scale and its subscales, including meaning and purpose in life, improved significantly in the intervention group (p < 0.05). Additionally, both groups demonstrated significant improvement in average Social Support Scale scores, whereas the average scores of subscales for affective support and communicative and appraisal support showed significant improvement in the intervention group only (p < 0.05, Table 3). 3.2.3. Between-group analysis for physical and psychological status Comparison between groups revealed no difference on the average number of physical symptoms (p = 0.757, Table 3) after involvement of the hospital-based palliative care team. However, the degree change for edema, fatigue, dry mouth, and abdominal distention in the intervention
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Table 1 Demographic characteristics and homogeneity test. Control group (n = 30)
Variable
Intervention group (n = 30)
Total (N = 60)
n
%
n
%
n
%
Gender Male Female
17 13
56.7 43.3
20 10
66.7 33.3
37 23
61.7 38.3
Age, average SD (57.52 14.62) 260 years old >60 years old
17 13
56.7 43.3
17 13
56.7 43.3
34 26
56.7 43.3
Education level Junior high school or below High school or above
13 17
43.3 56.7
14 16
46.7 53.3
27 33
45.0 55.0
Religious belief No Yes
8 22
26.7 73.3
6 24
20.0 80.0
14 46
23.3 76.7
Marital status Single Married Widowed
1 25 4
3.3 83.3 13.3
6 17 7
20.0 56.7 23.3
7 42 11
11.7 70.0 18.3
Disease diagnosed period/month, mean SD (31.90 64.32) 24 months >24 months
18 12
60.0 40.0
20 10
66.7 33.3
38 22
63.3 36.7
group showed significant improvement compared with the control group (p < 0.05, Table 4). There was no significant difference in anxiety and depression between the groups (Table 3).
X2
P value
0.635
0.426
0.000
1.000
0.067
0.795
0.373
0.542
5.913
0.052
0.287
0.592
and appraisal support in the intervention group were significantly higher than the control group (p < 0.05, Table 3). 4. Discussion
3.2.4. Between-group analysis for spiritual well-being and social support status The changes in scores for the Spiritual Well-Being Scale in the intervention group were significantly higher than the control group (p < 0.05, Table 3), whereas there was no significant difference in its subscales between the groups (Table 3). There were no significant changes for the Social Support Scale and its subscales for essential support and affective support between the groups (Table 3). However, the changes in scores for the subscale for communicative
The results of this study reveal that the hospital-based palliative care team had a positive impact on symptom management and spiritual well-being. To our knowledge, this study is one of the first to compare the effects of the hospital-based palliative care team with standard care, particularly in the Asia-Pacific region. Because many countries are planning to implement palliative care widely for advanced cancer patients’ needs, this research project has potential applicability to other settings.
Table 2 Homogeneity test for subscales in the baseline. Variable
Control (n = 30) mean SD
Intervention (n = 30) mean SD
Total (N = 60) mean SD
t
P value
Symptom Distress Scale Total number of symptoms
7.13 2.24
8.40 3.38
7.77 2.91
1.711
0.093
HADS Anxiety Depression
5.87 4.97 8.17 4.27
6.30 4.67 9.40 5.16
6.08 4.79 8.78 4.73
0.348 1.009
0.729 0.317
Spiritual Well-Being Scale Meaning and purpose in life Relationships with others and nature Support of a supreme being
3.76 0.43 3.69 0.54 3.85 0.37 3.68 0.83
3.58 0.52 3.43 0.68 3.74 0.41 3.68 1.32
3.67 0.48 3.56 0.63 3.80 0.39 3.68 1.09
1.435 1.633 1.162 0.000
0.157 0.108 0.250 1.000
Social Supportive Scale Essential support Affective support Communicative and appraisal support
3.40 0.51 3.32 0.59 3.52 0.52 3.42 0.58
3.33 0.48 3.15 0.46 3.57 0.61 3.35 0.56
3.37 0.49 3.23 0.53 3.54 0.56 3.38 0.57
0.611 1.221 0.342 0.499
0.544 0.227 0.734 0.620
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Table 3 Effects of the control group and the intervention group. Variable
Group
Pre
Post
Within group analysis
Mean
Mean
95% CI
Control Intervention
7.13 8.40
6.20 7.33
0.30 to 1.57 0.46 to 1.67
3.006 3.612
0.005 0.001
Control Intervention
5.87 6.30
4.87 4.93
0.53 to 2.53 0.50 to 2.24
1.338 3.217
0.191 0.003
Control Intervention
8.17 9.40
7.43 8.17
0.37 to 1.84 0.06 to 2.41
1.358 2.146
0.185 0.040
Control Intervention
3.76 3.58
3.75 3.68
0.06 to 0.07 0.17 to 0.02
0.102 2.656
0.919 0.013
Control Intervention
3.69 3.43
3.68 3.56
0.11 to 0.13 0.23 to 0.03
0.114 2.538
0.910 0.017
Control Intervention
3.85 3.74
3.84 3.80
0.05 to 0.07 0.17 to 0.04
0.414 1.287
0.682 0.208
Control Intervention
3.68 3.68
3.73 3.75
0.20 to 0.10 0.16 to 0.03
0.682 1.439
0.501 0.161
Control Intervention
3.40 3.33
3.46 3.42
0.11 to 0.15 to
2.188 3.661
0.037 0.001
Control Intervention
3.32 3.15
3.39 3.21
0.16 to 0.20 0.14 to 0.03
1.606 1.409
0.119 0.169
Control Intervention
3.52 3.57
3.55 3.67
0.10 to 0.03 0.17 to 0.03
1.072 3.026
0.293 0.005
Control Intervention
3.42 3.35
3.47 3.48
0.13 to 0.02 0.21 to 0.05
1.439 3.440
0.161 0.002
t
Between group analysis P value
Symptom Distress Scale Total number of symptoms
HADS Anxiety
Depression
Spiritual Well-Being Scale
Meaning and purpose in life
Relationships with others and nature
Support of a supreme being
Social Supportive Scale 0.00 0.04
Essential support
Affective support
Communicative and appraisal support
a
t or za
P value
t = 0.311
0.757
t = 0.427
0.671
t = 0.634
0.529
t=
2.061
0.044
t=
1.761
0.084
t=
1.320
0.192
t=
0.192
0.848
z=
1.888
0.059
z=
0.977
0.329
z=
1.273
0.203
z=
2.034
0.042
Independent-samples T test (normal distribution variables); Mann–Whitney U test (non-normal distribution variables) for between group analysis.
In this study, the hospital-based palliative care team improved the care for patients in relation to symptom management. The reason for this is the fact that nurses in the hospital-based palliative care team had undergone hospice-training programs and had become specialists (Morita et al., 2005). This underlines the purpose of the hospital-based palliative care team: to bring the principles of hospice and palliative care to acute hospital settings and provide better palliative care according to each patient’s suffering and individual care needs. Specifically, we found that nurses in the hospital-based palliative care team advised patients to get more exercise, taught them and their families to perform lymphatic massage, and used elastic compression garments to reduce edema, even though limb elevation for edema is the routine in acute hospital settings. These interventions are recommended by Erickson et al. (2001) as well. Nurses also encouraged patients to engage in exercise tolerably to decrease the sensation of fatigue which has been supported by Wagner and Cella (2004). They also suggested using lip cream for dry mouth, petroleum jelly to prevent dry lips, or mouth care with tea instead of
moistening the mouth with wet cotton swabs (McCann et al., 1994). If patients experienced abdominal distention, the nurses would inspect their bowel movement status. If patients had constipation or the frequency of their bowel movements decreased, nurses in the hospital-based palliative care team would investigate the underlying cause of constipation first and then would suggest the staff in the acute hospital settings add prokinetic agents or laxatives to patients’ drug regimens if needed (Larkin et al., 2008; Schiller, 2004). If patients’ elimination improved, their abdominal distention improved as well. To improve appetite loss, health professionals in the hospital-based palliative care team suggested patients eat smaller amounts of food and more times each day (Twycross et al., 2009). When patients complained of dizziness, the hospital-based palliative care team would assess the laboratory data and discuss the use of blood transfusions with staff in the acute hospital settings. These findings showed the hospital-based palliative care team could reduce the degree of distressing physical symptoms, which is consistent with the reports of previous studies (Bakitas et al., 2009; Hsu et al., 2007). Additionally, the
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Table 4 Changes of degree about physical symptoms (control, n = 30; intervention, n = 30). Variable
Group
Pre
Post
Within group analysis
Mean
Mean
95% CI
t
Between group analysis P value
1. Pain Control Intervention
2.87 2.95
2.17 1.77
0.27 to 1.12 0.72 to 1.65
3.425 5.266
0.002 0.000
Control Intervention
4.96 4.86
3.87 2.68
0.33 to 1.85 1.19 to 3.17
2.969 4.571
0.007 0.000
Control Intervention
2.25 2.45
1.50 1.65
0.22 to 1.28 0.33 to 1.27
3.000 3.559
0.009 0.002
Control Intervention
1.93 2.00
1.43 1.31
0.13 to 1.13 0.21 to 1.59
1.713 1.671
0.110 0.121
Control Intervention
1.55 2.37
0.55 1.94
0.15 to 1.85 0.21 to 1.08
0.622 1.447
0.026 0.168
Control Intervention
3.00 2.21
1.80 1.64
0.16 to 2.24 0.08 to 1.06
3.207 2.511
0.033 0.026
Control Intervention
4.00a 1.80
4.00a 1.20
0.08 to 1.28
2.449
0.070
Control Intervention
3.00 3.20
3.25 2.60
1.05 to 0.55 0.17 to 1.37
1.000 1.765
0.391 0.111
Control Intervention
2.09 2.44
1.91 1.50
0.22 to 0.59 0.37 to 1.50
1.000 3.529
0.341 0.003
Control Intervention
2.67 3.35
2.56 2.50
0.29 to 0.51 0.39 to 1.30
0.570 3.851
0.574 0.001
Control Intervention
2.50 2.29
1.72 1.94
0.11 to 1.45 0.48 to 1.18
2.439 0.899
0.026 0.382
Control Intervention
3.00 3.29
2.17 2.43
0.39 to 2.06 0.13 to 1.85
1.746 2.121
0.141 0.078
Control Intervention
2.52 2.96
2.30 2.12
0.15 to 0.59 0.37 to 1.33
1.226 3.627
0.233 0.001
Control Intervention
2.76 3.00
2.59 2.35
0.24 to 0.59 0.19 to 1.11
0.899 2.942
0.382 0.008
Control Intervention
2.22 3.24
1.78 1.81
0.01 to 0.90 0.86 to 2.00
2.046 5.246
0.057 0.000
Control Intervention
1.95 2.21
1.50 1.68
0.04 to 0.94 0.19 to 0.86
1.917 3.293
0.070 0.004
Pain score (0–10)
2. Dyspnea
3. Nausea/vomit
4. Constipation
5. Dysphagia
6. Oral ulcer
7.Ascites
8. Edema
9. Fatigue
10. Insomnia
11. Stool and urine incontinence
12. Dry mouth
13. Appetite loss
14. Abdominal distention
15. Dizziness
a
t
P value 0.937
0.353
1.262
0.212
0.976
0.333
0.253
0.801
0.247
0.806
0.628
0.532
0.226
0.822
1.516
0.139
2.443
0.019
2.580
0.012
1.208
0.232
0.417
0.678
2.274
0.027
1.987
0.052
2.796
0.007
0.626
0.534
SD is 0, cannot calculate t value.
hospital-based palliative care team members also assessed patients’ physical needs to reduce unnecessary artificial nutrition and hydration in order to relieve their edema, dyspnea, and anorexia (Ke et al., 2008). It is noteworthy that patients’ pain control, dyspnea, and dysphagia underwent significant improvements in both
groups. This implies that continued education for cancer symptom management plays a role enabling the health professionals in the acute hospital settings to assist their patients. This might also be the result of cross-contamination. The staff in the acute hospital settings had reviewed the notes from the hospital-based palliative care team, and they
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might also have witnessed the team members providing care to the patients. This could also assist the staff from acute hospital settings to care for patients who did not receive the care from the hospital-based palliative care team but had the same symptoms. Another reason is that these symptoms can be improved by drugs, so there was not a significant improvement from the hospital-based palliative care team compared with the acute hospital settings. We also found that patients’ spiritual well-being improved significantly after receiving care from the hospital-based palliative care team for one week, whereas their anxiety and depression status did not improve compared with the control group. The reason for the improvement of spiritual well-being is to assist in truth telling (Leung et al., 2006). After consulting the hospitalbased palliative care team, if patients wished to know their disease prognosis, the team members would assist the acute hospital settings in dealing with this issue. When patients are aware that death is forthcoming, they tend to refocus their hope on ‘‘being’’ rather than ‘‘doing,’’ to emphasize relationships with others and with God, and to explore beliefs regarding life after death. Therefore, awareness of terminal illness may become a turning point, at which people begin to deal with their spiritual needs and reach a better level of spiritual well-being (Leung et al., 2006). In line with this, their families will often be freed from the pressure of truth telling and be able to have a clear communication with the patients, helping them to make an appropriate decision for future treatments or care (Huang et al., 2008; Yang et al., 2011). Therefore, it becomes easier for patients and their families to communicate and prepare advance directives. Patients can feel less lonely in accepting their incurable status and face their death much more peacefully (Yang et al., 2011). However, patients in both groups underwent emotional suffering, such as involved in truth telling or facing death. Even though the hospital-based palliative care team had assisted them to deal with these issues, patients needed more time to adjust to these emotional impacts, and one week is not long enough to measure the effects. These findings were consistent with the research by Morita et al. (2005b) and O’Mahony et al. (2005). They pointed out that hospital-based palliative care teams did not improve patients’ emotional disturbances efficiently over a single week. Although our findings show the hospital-based palliative care team model provided effective care, there are nonetheless some sampling concerns that might influence our study results. These included: (1) patients or their families who refused the hospital-based palliative care team service were assigned to the control group; and (2) there was a higher proportion of unmarried patients who chose the hospital-based palliative care team service, even though there was no statistical significant difference. Considering patients’ desire to choose the different care models, we were unable to assess the impact of sample selection bias, which may have implications for the generalizability of the findings. As a result, we need to be careful in interpreting the effect of the hospital-based palliative care team in our study. Furthermore, there are some problems in the model in Taiwan. Due to the limited number of members of the
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hospital-based palliative care team, they usually visit each patient only two or three times per week and sometimes do not have enough communication with the acute hospital settings. As a result, the hospital-based palliative care team members often make up for the lack of conversations by writing notes in the medical chart. Sometimes, health professionals in the acute hospital settings may miss these messages and as a result do not manage patients’ problems in a timely way. These problems were also reported by Morita et al. (2005a) and Rabow et al. (2003). To resolve these problems, we suggest that hospital-based palliative care teams and acute hospital settings should use the same standard assessment tools, have regular meetings, and increase the frequency of patient visits. In this study, nearly 46% of patients consulted the hospital-based palliative care team for symptom management or death preparation (98/214) but were ineligible for the study requirements because they were in a coma or likely to die. This reflects the issue of late referrals, which is consistent with the reports by Morita et al. (2005a) and Rabow et al. (2003). In clinical practice, when patients were referred to the hospital-based palliative care team late, the time for families’ preparation for deterioration of the patients’ condition was insufficient and the hospitalbased palliative care team only could provide limited assistance. Therefore, early referral to the hospital-based palliative care team is recommended. Certain limitations in this study should be mentioned. First, patients were divided into two groups according to whether or not they wished to receive the care from the hospital-based palliative care team. Due to ethical and practical consideration, the patients in the study could not be randomly assigned to two groups. The study was therefore conducted as a quasi-experimental design. Since respect for autonomy remains the basic ethical principle in most countries, this study design can be justified. Second, a 1-week follow-up time was used to consider the patients’ condition. This might only reflect the short term issues in the care such as symptom management. However, more time may be needed to deal with patients’ needs involving emotional disturbances and social support. Third, there was no standard checklist to evaluate the quality of the hospital-based palliative care team at the beginning of this model’s implementation in Taiwan, so the study used a series of questionnaires to measure. As a result, a total of 60 patients were recruited from 214 consecutive subjects. The representativeness of end-of-life subjects and effects on the hospital-based palliative care team may be limited. The last point is that this study only applies to a hospital population with a small sample size, so the generalizability of the results may be a concern. Although there has been similar patient demographic data within hospitals with hospital-based palliative care teams in Taiwan, according to reports from DOH in Taiwan, there is always a possibility that institutions may have differed on other variables as well. Hence, further rigorous sampling strategies from multiple sites should be conducted to recruit larger samples. We also recommend the further studies could recruit at least 41 participants in each group in order to find a difference in pain level between groups. It is based
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on the pain score data in the study with a power of 80% and alpha level of 0.05. 5. Conclusion This was the first project to evaluate the effect of hospital-based palliative care teams on care for cancer patients in Taiwan. The findings show that hospital-based palliative care teams can improve care for advanced cancer patients, especially for symptom management and spiritual well-being. Even though there are still some problems to be overcome in the implementation of hospital-based palliative care teams in Taiwan, these results also provide a general understanding about the outcomes of the hospital-based palliative care team in Taiwanese culture. We found communication and late referrals are barriers when attempting to improve the service quality of the hospital-based palliative care team. Members of hospital-based palliative care teams and acute hospital staff are encouraged to have regular meetings to improve their communication and provide patients and their families with more efficient care, and early referral is recommended. In view of the small sample size and a 1-week follow-up period, it would be desirable to conduct additional studies using larger samples to explore long-term effects of the hospital-based palliative care team on the clinical practice. In conclusion, the hospital-based palliative care team is a good care model for patients, and its implementation in clinical practice should be continued. Conflict of interests None of the authors have any conflicts of interests with regards to this research. Funding None. Ethical approval Ethics committee from the National Taiwan University Hospital. Acknowledgements The authors thank the medical staff and the hospitalbased palliative care team members of National Taiwan University Hospital for their full support. References Bakitas, M., Lyons, K.D., Hegel, M.T., Balan, S., Brokaw, F.C., Seville, J., et al., 2009. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA 32 (7) 741–749. Barrera, M.J., 1981. Social support in the adjustment of pregnant adolescents: assessment issues. In: Gottlieb, B.H. (Ed.), Social Network and Social Support. Sage, London, pp. 69–96. Cassel, B.J., Kerr, K., Pantilat, S., Smith, T.J., 2010. Palliative care consultation and hospital length of stay. Journal of Palliative Medicine 13 (6) 761–767.
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