My objective was to investigate the experiences of women diagnosed with metastatic breast cancer.

I did a qualitative study based on interview data. Fourteen women with metastatic breast cancer were recruited into a larger study of online support group use. Participants were interviewed by phone.

The women indicated that they experience distress because of concerns about body image, declines in aspects of their sexual lives, and worries about the effect of stress on their illness. The stress that worries these women comes from fear of dying, fear of disease progression and debilitation, the loss of their future, and practical concerns. The women were also likely to experience a decline in daily activity after being diagnosed with metastatic disease. They become less active because of the physical symptoms of the illness and the side effects of treatments, the medicalization of their lifestyle, their desire to avoid stressful situations, the constraints imposed by their social world, and the need to maintain disability benefits. Although women are often in need of emotional and material support from others after they are diagnosed, social support can decrease, both because women find it difficult to be open about the difficulties they face and because the responses of others are not adequately supportive. Distress and declines in daily activity and social support can feed into each other to create a vicious circle.

This paper makes a significant contribution to the literature by providing a rich description of how metastatic breast cancer affects women. Further research, with more diverse samples, is needed in this understudied area.

Most patients diagnosed with lung cancer present with advanced stage disease and have a poor chance of long-term survival. Despite the advantages of hospice care for lung cancer patients, many are enrolled late in the course of their illness or not at all. We sought to identify reasons for this pattern.

A list of perceived barriers to hospice enrollment was generated and used to create two self-administered surveys, one for physicians and one for caregivers. After focus group testing, the finalized instruments were mailed to physicians in South Carolina and to caregivers of lung cancer patients who died under hospice care with a local hospice between 2000 and 2004.

Fifty-three caregivers and 273 physicians responded to the survey. From the caregivers' perspectives, leading reasons for deferred hospice enrollment included patients' unanticipated rapid transition from well to sick and a belief that hospice means giving up hope. From the physicians' perspectives, impediments to earlier hospice enrollment included patients and caregivers overestimating survival from lung cancer and an (incorrect) assumption that patients need to be “DNR/DNI” prior to hospice enrollment.

Lung cancer patients may benefit from earlier introduction to the concepts of hospice care and more education regarding prognosis so that an easier transition in goals of care could be achieved. A smaller proportion of lung cancer patients may benefit from earlier hospice enrollment.

The loss of a child can be traumatic for parents, given the profound bond established with the deceased child. Parental bereavement and the need for bereavement services are not well understood. This study examined parental perspectives regarding bereavement services from a pediatric oncology treating center.

A 2-h focus group of seven parents, audiotaped and transcribed verbatim, was conducted by two facilitators using open-ended questions to generate discussion regarding their views of what services were or would be helpful during early bereavement.

Parents perceived flexible and continuous bereavement services from the treating hospital as a necessary transition to community services. Talking to other parents with similar experiences and maintaining contact with staff at the treating hospital were considered critical in their healing after the loss.

Transitional multimodality bereavement services offered by the treating hospital will improve the quality of life of bereaved families.

Increasing awareness of well-being aspects of physical touch has spurred the appreciation for soft tissue massage (STM) as part of palliative care. Educational programs are available but with no specific focus on utilization for this kind of care. The aim was to study the feasibility of a 1-day course in STM in clarifying nursing staff's experiences and opinions, but also to shed light on their motivation and ability to employ STM in the care of dying cancer patients.

In all, 135 nursing staff participated. The course consisted of theory and hands-on training (hand-foot-, back massage). Focus-groups with 30/135 randomly chosen participants were conducted 4 weeks after the intervention. This study engaged a qualitative approach using content analysis.

The overall opinion of the 1-day course was positive. The majority experienced the contents of the course to be adequate and sufficient for clinical care. They emphasized the pedagogical expertise as valuable for the learning process. The majority of nurses shared the opinion that their extended knowledge clarified their attitudes on STM as a complement in palliative care. Still, a few found it to be too basic and/or intimate. Three categories emerged during the analysis: experiences of and attitudes toward the education, experiences of implementing the skills in every-day care situations, and attitudes to the physical body in nursing care.

The approach to learning and the pedagogical skills of the teacher proved to be of importance for how new knowledge was perceived among nurses. The findings may encourage hospital organizations to introduce short courses in STM as an alternative to more extensive education.

To assess the feasibility of an 8-week bereavement support group in a general hospital setting.

We assessed grief and mood before and after an 8-week bereavement support group and compared dropouts to completers. Forty-seven participants filled out mood and grief questionnaires. Scores were compared with norms, then baseline and follow-up scores were analyzed by paired t tests. Fifteen dropouts' scores were compared with completers' baseline scores.

Participants' grief improved, as did depression in women but not men. Women dropouts scored significantly higher on Anger, Tension/Anxiety.

Findings suggest men and women respond differently to bereavement groups. Bereaved individuals with high anger and tension may require interventions addressing their particular needs, with a focus on acceptance of negative emotions.

The current literature on caregiving and bereavement indicates that the relationship between these two common life events is complex and needs to be further studied in order to gain a more comprehensive understanding of their interaction.

In the current project, 50 spouses of hospice patients with end-stage lung cancer or dementia were assessed while caregiving and at an average of 4 months after the death on a variety of measures, including caregiving stressors, appraisals, social resources, and well-being. A stress process model was utilized in order to examine which preloss factors were associated with postloss depression, life satisfaction, and grief.

Our results indicated that patient diagnosis (cancer or dementia) and caregiver appraisals (stressfulness of functional impairment and positive aspects of caregiving) were not predictors on any of our well-being outcomes. However, fewer months caregiving was a significant predictor of both higher depression and grief postloss. Additionally, lower levels of social activities, smaller social networks, and lower satisfaction with social support were significantly associated with higher postloss depression.

Results support both the resource depletion and anticipatory grief hypotheses and suggest that short-term bereavement outcomes are different than factors that predict well-being while caregiving. Future studies should address whether long-term bereavement outcomes differ by baseline caregiving characteristics to guide intervention research.

The diagnosis of terminal cancer begins one of the most complex and challenging individual experiences of human life that requires multiple coping responses, one of those being hope. There are few studies that provide descriptions of hope over time for adults, ages 20–59, with advanced stage cancer. The purpose of this study was to describe hope as defined and experienced by young and middle age adults with advanced stage cancer.

This descriptive, longitudinal qualitative research study interviewed 12 hopeful adults with advanced stage cancer once a month for 3 months.

By definition, this population exhibited high levels of hope at study entry. Hope scores did not change overtime. Four qualities associated with high levels of hope included: reliance on strong spiritual beliefs, maintenance of positive attitudes, accommodation of cancer symptoms, and the presence of supportive resource people. The emphasis or importance of each quality and specific hope related goals were determined and defined individually. Hope goals varied in degree of expectancy and concreteness and require reassessment as conditions change.

By identifying an individual's hope goals, palliative care clinicians can then plan and implement interventions to move toward that hope goal.

To examine the attitudes of Iranian nurses toward caring for dying patients.

Nurses' attitudes toward death and caring for dying patients were examined by using two types of questionnaires: the Death Attitude Profile–Revised (DAP-R) and Frommelt's Attitude towards Caring for Dying Patients (FATCOD), both with a demographic survey.

The results showed that most respondents are likely to view death as a natural part of life and also as a gateway to the afterlife. The majority reported that they are likely to provide care and emotional support for the people who are dying and their families, but they were unlikely to talk with them or even educate them about death. They had a tendency not to accept patients and their families as the authoritative decision makers or involve families in patient care. Nurses' personal views on death, as well as personal experiences, affected their attitudes toward care of the dying.

Lack of education and experience, as well as cultural and professional limitations, may have contributed to the negative attitude toward some aspects of the care for people who are dying among the nurses surveyed. Creating a reflective narrative environment in which nurses can express their own feelings about death and dying seems to be a potentially effective approach to identify the factors influencing their interaction with the dying. Continuing education may be required for Iranian palliative care nurses in order to improve the patients quality of care at the end of life.

To evaluate the use of the Mood and Symptom Questionnaire (MSQ) within a program of structured psychosocial interventions in a Supportive and Palliative Care Center. Palliative care patients have a range of psychological symptoms as well as physical symptoms. Considerable expertise in controlling pain and fear of pain, other physical symptoms, and psychosocial distress has been built up in hospices and palliative care units. This expertise can be used even at late stages in the patient's illness to improve quality of life.

We evaluated the usefulness of the MSQ to record patient responses, as an aid to patient/staff discussions, and as a staff-training tool. The questionnaire consisted of visual analog scales completed by the patient with a staff member present. Using the tool increased the opportunities for staff and patients to discuss problematic psychosocial issues. Where possible, we obtained data at two time points and compared the responses.

The MSQ was rapidly accepted as a clinical tool in the day therapy setting by staff and the patients. The process of completing the questionnaire encouraged patients to face and discuss difficult issues. Discussion of the issues raised on the questionnaire had a wider effect, influencing interactions and communications through the unit and facilitating wider discussion of other nonpain symptoms. The medical psychotherapist associated with the unit used the MSQ responses as a training tool to increase staff awareness and knowledge and understanding of psychological issues related to the patients' total pain experience by discussing the questionnaires with them.

The use of this tool helped to identify some psychological issues that proved relatively straightforward to address once uncovered. Patients benefited from this opportunity when their remaining time was relatively short. Their quality of life at the end of their lives was improved.

Familial caregivers are providing increasing amounts of care to advanced cancer patients. Increased understanding of caregivers’ needs is vital in providing necessary support to lessen caregiver burden and morbidity. Current literature has identified caregiver and patient needs at broad stages of the cancer trajectory; however, such broad stages may be too general to inform a practice of targeting specific interventions when they have the greatest utility. This study examines a variety of particular needs across a number of more discrete illness-related transition experiences specifically in the advanced cancer disease trajectory.

One hundred fifty-nine female informal caregivers of people with advanced cancer completed a needs assessment survey.

Analyses of these cross-sectional retrospective-report data reveal that cancer caregiver needs vary across specific key experiences occurring within the broader stages of illness identified by current literature. Furthermore, caregivers have unique needs during bereavement.

Although the sample characteristics are demographically limited, this study provides preliminary evidence that the broad stages are not specific enough increments for effectively examining caregiver needs and supports the need for more precise distribution of cancer-related information at more discrete times in the illness course.

Delirium is prevalent, difficult to assess, under-recognized, and undertreated in hospice and palliative care settings. Furthermore, it is associated with significant morbidity and mortality. Under-recognition of delirium results in under-treatment and increased suffering. The intent of this study was to retrospectively evaluate the recognition of delirium in a large cohort of hospice patients by interdisciplinary hospice care teams.

A retrospective chart review of 2,716 patients receiving hospice care was conducted in order to determine the baseline rate of recognition of delirium in patients with advanced, life-threatening illnesses by front-line hospice clinicians. Documentation of “delirium” as either a diagnosis or problem was used as an estimate of how often these disorders were considered significant issues by the treating interdisciplinary team.

Of the patients receiving home/long-term care, 17.8% (386/2168) had delirium documented as a diagnosis or significant problem. The presence of recognized delirium in this setting was associated with significant differences in marital status, ethnicity, hospice diagnosis, and age. Total length of hospice care was also significantly longer. Of patients receiving inpatient care, 28.3% (614/548) had delirium documented as a diagnosis or significant problem. Recognized delirium in this setting was associated with significant differences in gender, ethnicity, hospice diagnosis, and length of inpatient stay.

If documentation is representative of the care that the interdisciplinary teams provide, delirium of any kind appears to be under-recognized in this population. In fact, it is on the low end of prevalence estimates in the literature. Improved delirium assessment is needed in order to minimize the impact of delirium on patients living with advanced, life-threatening illnesses and their caregivers.

Oral mucositis (OM) is a frequently encountered problem as a complication of cancer treatment. We investigated whether daily washings with colchicine solution improved mucositis in patients with hematological malignancies undergoing chemotherapy.

This study was a one-arm, nonrandomized clinical trial that used a historical control group. Patients were included in the study from the first day of mucositis and followed up until discharge. Patients received 2 mg colchicine mouthwashes daily for 5 days or saline solution. OM was assessed once daily until symptom resolution, using the WHO grading scale of 0–4 and a visual analogue scale. We determined that at least 40 patients in the colchicine group would be needed to detect a 20% difference in the duration of OM between Groups A and B, with a 95% confidence level and a power of 80%.

82 patients were included in the final analysis, 40 in the colchicine group and 42 in the control group. Median duration of OM was significantly different among groups; 9days (range 1–17days) for the control group versus 6days (range 3–13days) for those exposed to colchicine mouthwash (p = .028). The median days of regression of mucosal lesions were significantly different (p = .047) among the control group (7 days [range 3–20]) compared to the colchicine group (4 days [range 2–14]).

Although our findings suggest that colchicine mouthwash is helpful in reducing the severity and duration of chemotherapy-induced OM, randomized trials are needed to confirm these results.

The aim of this article is to review the available literature on depression in women with metastatic breast cancer in terms of prevalence, potential risk factors, and consequences, as well as pharmacological and psychological interventions.

An extensive review of the literature was conducted.

The prevalence of depression appears to be especially elevated in patients with advanced cancer. Many demographic, medical, and psychosocial factors may increase the risk that women will develop depressive symptoms during the course of their illness. Despite the fact that depression appears to be associated with numerous negative consequences, this disorder remains underdiagnosed and undertreated. Both pharmacotherapy and psychotherapy have been found to treat effectively depressive symptoms in this population, but cognitive-behavioral therapy appears to be the most cost-effective approach.

Areas for future research are suggested.

Persons with ALS differ from those with other terminal illnesses in that they commonly retain capacity for decision making close to death. The role patients would opt to have their families play in decision making at the end of life may therefore be unique. This study compared the preferences of patients with ALS for involving family in health care decisions at the end of life with the actual involvement reported by the family after death.

A descriptive correlational design with 16 patient–family member dyads was used. Quantitative findings were enriched with in-depth interviews of a subset of five family members following the patient's death.

Eighty-seven percent of patients had issued an advance directive. Patients who would opt to make health care decisions independently (i.e., according to the patient's preferences alone) were most likely to have their families report that decisions were made in the style that the patient preferred. Those who preferred shared decision making with family or decision making that relied upon the family were more likely to have their families report that decisions were made in a style that was more independent than preferred. When interviewed in depth, some family members described shared decision making although they had reported on the survey that the patient made independent decisions.

The structure of advance directives may suggest to families that independent decision making is the ideal, causing them to avoid or underreport shared decision making. Fear of family recriminations may also cause family members to avoid or underreport shared decision making. Findings from this study might be used to guide clinicians in their discussions of treatments and health care decision making with persons with ALS and their families.

In the clinical setting of cancer, meaning may well have a central role in the life changes the illness experience brings about. As health care professionals working with people with life-threatening illness, we are exposed to one of the major turning points in life and the ways people confront this transition. Meaning can assist coping by offering a framework, perspective, and counterbalance to the challenge of illness. However, the absence of meaning can be a precursor to profound despair.

This article brings together the clinical implications of two studies conducted by the authors that explored the role of meaning in adjustment to cancer, presenting a theoretical understanding of the experience of meaning in cancer and identifying some potential approaches to intervention.

Our findings point to some specific goals of care as well as a number of therapeutic modalities aimed to meet these goals. We examine four goals of care—acknowledging suffering, encouraging a search for meaning, strengthening connection with others, and ensuring optimal physical care—as foundational in any clinical approach and then examine the key models of therapy that assist the clinician in pursuing these goals.

Our aim is to create an integrated approach to care provision that locates meaning centrally in any patient's adaptation.

Medical education can be described as a socialization process that has a tendency to produce doctors who struggle to convey to patients that they care. Yet, for people who are suffering, to enjoy the quality of life they are entitled to, it is important that they feel cared for as people, rather than simply attended to as patients.

This article addresses how we teach medical students the art of caring for the person rather than simply treating the disease—a question particularly relevant to end-of-life care where, in addition to the physical needs, attention to the psychosocial, emotional, and spiritual needs of the patient is paramount. Following an overview of what it is to care and why it is important that patients feel cared for, we investigate how we learn to care and develop caring human relationships, describing the development and display of empathy in adulthood and the developmental impact of human interaction.

We outline evidence of situational barriers to effective education about care in medicine including role models, ward culture, and the socialization process.

We then propose a model for medical education based on patient contact, reflection, self-care, role model development, and feedback that will see students learn the art of human care as well as the science of disease management.

Delirium is the most common neuropsychiatric complication of medical illness, a medical emergency that needs to be identified and treated vigorously. Delirium is too frequently underdiagnosed and untreated in the medical setting, which leads to increased morbidity and mortality, interference in the management of symptoms such as pain, an increased length of hospitalization, increased health care costs, and distress for patients and their caregivers (Inouye, 2006; Breitbart et al., 2002a, 2002b). In this article, we present an update of the use of antipsychotics in management of delirium based on the available literature and our own clinical experience.

We reviewed the current literature on the role of antipsychotics in the management of delirium using standard computer-based search methods (e.g., PubMed).

Antipsychotic medications, including the new atypical antipsychotics, have been demonstrated to effectively manage a wide spectrum of the symptoms of delirium and are an essential component in the multimodal approach to managing delirium.

The standard approach to managing delirium includes identification and elimination of factors contributing to the delirium in addition to pharmacological and nonpharmacological treatment interventions (Trzepacz et al., 1999). Newer atypical antipsychotics can play an important role in the management of the symptoms of delirium.

The authors describe the concept of hospice formulary as is utilized at the hospice service of a university medical center.

A periodic review of hospice formulary, focusing on psychotropic medications and delirium prevention, was accomplished in 2006. This effort represents a multidisciplinary effort among hospice nursing, internal medicine, and psychiatry.

An updated formulary adopting contemporary psychopharmacologic best practices was produced and implemented along with targeted in-service training to nurse clinicians.

The modern hospice formulary offers opportunities to offer state-of-the-art psychopharmacological care and minimization of delirium through judicious use of psychopharmacological treatments for the psychiatric comorbidities common in terminally ill patients.