Jenni Burt

The experiences of older adults in the community dying from cancer and non-cancer causes: a national survey of bereaved relatives

BACKGROUND there is limited understanding of symptoms and care in the last few months of life for adults dying from causes other than cancer. OBJECTIVE the aim of the study is to compare the experiences in the community in the last 3 months of life of older adults dying from cancer and non-cancer causes. DESIGN the study employed a retrospective cross-sectional survey of bereaved relatives. SETTING the survey took place across eight cancer networks in England. SUBJECTS a random sample of 1,266 adults who registered a death occurring in someone aged 65 and over between August 2002 and February 2004 was drawn. METHODS VOICES (Views of Informal Carers-Evaluation of Services) questionnaires were sent to sampled informants by the Office for National Statistics 3-9 months after the registration of the death. Differences in the reported experiences of cancer and non-cancer decedents in symptoms, treatment and care were assessed using Pearsons chi square test. RESULTS cancer decedents were significantly more likely than non-cancer decedents to have had pain (93 vs 79%, P < 0.001), nausea and vomiting (62 vs 40%, P < 0.001) and constipation (74 vs 66%, P = 0.03), whilst a greater proportion of non-cancer decedents experienced breathlessness (74 vs 65%, P = 0.006). Across both groups, less than half of the decedents were reported to have received treatment which completely relieved their symptoms some or all of the time. There were significant variations in the receipt of district nursing, general practitioner care and other health and social care and the reported quality of this care, for decedents dying of cancer and non-cancer causes. Further, informants for cancer deaths reported greater satisfaction with support received. CONCLUSIONS there are important differences in the reported experiences of older adults dying from cancer and non-cancer causes in the last months of life, independent of age.

Equity of use of specialist palliative care by age: cross-sectional study of lung cancer patients:

The equitable provision of care is a core principle of the National Health Service. Previous research has suggested that older cancer patients may be less likely to use specialist palliative care, but such research has been limited by retrospective design and the failure to measure clinical need. The objective of this study was to examine the extent to which the use of specialist palliative care in lung cancer patients varies by age, after accounting for need. A cross-sectional survey of patients and their carers attending four hospital lung cancer clinics in London was conducted between June 2006 and April 2007. Two hundred and fifty-two patients and 137 carers participated in the study. Thirty-nine percent of participants received specialist palliative care. Metastatic disease, global quality of life and the clinic where treatment was provided were associated with use of specialist palliative care. Age, gender, deprivation, living alone, current or most recent line of treatment, number of co-morbidities and carer stress were not associated with receipt of such services. This suggests that, for patients within the specialist cancer care system, access to specialist palliative care is offered on the basis of need.

Back to basics: researching equity in palliative care:

Recent debate on the provision of palliative care as an international human right has included the assertion that there should be equity of access to services for all, without discrimination.1 Few would argue with the merits of such an aim. Few also would argue that current evidence points to serious inequalities; at a global level, the lack of palliative care provision in many settings remains a fundamental issue. However, even within countries with well-developed palliative care, differential access has been reported for patients as a result of characteristics including age, ethnicity and socioeconomic status. This has led to the widespread assumption that there is inequitable provision of care. This may indeed be the case. However, for the presence of inequity to be determined, a few key theoretical concepts need to be understood. So, before considering what we know about equity in palliative care (not as much as we think, it turns out), I present a brief refresher of some crucial definitions. In 1992, Margaret Whitehead published an influential paper on equity and health that defined health inequities as differences in health which were unnecessary, unfair and unjust.2 She went on to offer three possible definitions of equity in healthcare: