Michelle Winslow

Attitudes of Health Care Professionals to Opioid Prescribing in End-of-Life Care: A Qualitative Focus Group Study

CONTEXT Opioid therapy is central to the management of pain in the field of generalist palliative and end-of-life care, and international guidelines highlight the need for opioids to be used as part of a comprehensive strategy to treat pain. However, evidence suggests that the use of opioids in palliative care is suboptimal, and many patients do not receive adequate pain control at the end of life. OBJECTIVES This study aimed to explore the attitudes of health care professionals to opioid prescribing in generalist end-of-life care. METHODS Thirty-one health and allied health professionals participated in four focus groups. Two focus groups took place in general practitioner practices and two in hospices. RESULTS Findings revealed that significant barriers exist to the appropriate use of opioids in end-of-life care. Particular barriers exist for professionals working in primary care and include concerns about giving high doses and having insufficient training in opioid use. Working partnerships between specialist and generalist palliative care providers are important for increasing generalist confidence in prescribing. Patients and their families often have concerns about initiating opioids, and specialist nursing staff are crucial to managing and alleviating these concerns. CONCLUSION Significant barriers exist to the appropriate use of opioids in end-of-life care. If international priorities on improving pain management at the end of life are to be achieved, educational opportunities for generalists need to be enhanced, and effective interprofessional working models need to be developed so that pain management for patients at the end of life is optimized.

The views of older women towards mammographic screening: a qualitative and quantitative study.

Background:Mammographic screening has improved breast cancer survival in the screened age group. This improved survival has not been seen in older women (>70 years) where screening uptake is low. This study explores the views, knowledge and attitudes of older women towards screening.Methods:Women (>70 years) were interviewed about breast screening. Interview findings informed the development of a questionnaire that was sent to 1000 women (>70 years) to quantify their views regarding screening.Results:Twenty-six women were interviewed and a questionnaire was designed. The questionnaire response rate was 48.3% (479 out of 992). Over half (52.9%, 241 out of 456) of the respondents were unaware that they could request a mammography by voluntary self-referral and were unaware how to arrange this. Most (81.5%, 383 out of 470) had not attended breast screening since turning 70 years. Most (75.6%, 343 out of 454) felt screening was beneficial and would attend if invited. Most (90.1%, 412 out of 457) felt screening should be offered to all women regardless of age or health.Conclusions:There is a lack of knowledge about screening in older women. The majority felt that invitation to screening should be extended to the older age group regardless of age or health. The current under-utilised system of voluntary self-referral is not supported by older women.

Can comprehensive specialised end-of-life care be provided at home? Lessons from a study of an innovative consultant-led community service in the UK

The Midhurst Macmillan Specialist Palliative Care Service (MMSPCS) is a UK, medical consultant-led, multidisciplinary team aiming to provide round-the-clock advice and care, including specialist interventions, in the home, community hospitals and care homes. Of 389 referrals in 2010/11, about 85% were for cancer, from a population of about 155 000. Using a mixed method approach, the evaluation comprised: a retrospective analysis of secondary-care use in the last year of life; financial evaluation of the MMSPCS using an Activity Based Costing approach; qualitative interviews with patients, carers, health and social care staff and MMSPCS staff and volunteers; a postal survey of General Practices; and a postal survey of bereaved caregivers using the MMSPCS. The mean cost is about 3000 GBP (3461 EUR) per patient with mean cost of interventions for cancer patients in the last year of life 1900 GBP (2192 EUR). Post-referral, overall costs to the system are similar for MMSPCS and hospice-led models; however, earlier referral avoided around 20% of total costs in the last year of life. Patients and carers reported positive experiences of support, linked to the flexible way the service worked. Seventy-one per cent of patients died at home. This model may have application elsewhere.

Changing technologies of cancer pain relief: themes from the twentieth century

Michelle Winslow*, David Clark, Jane Seymour, Bill Noble*, Henk ten Have, Marcia Meldrum**, Silvia Paz* *Academic Palliative M edicine Unit, University of Sheffield, UK Institute for Health Research, Lancaster University, UK ‡School of Nursing and M idwifery, University of Sheffield, UK Division of Ethics of Science and Technology, Paris, France **Department of History, University of California, Los Angeles, US A

Consumer views on a new holistic screening tool for supportive and palliative-care needs: Sheffield Profile for Assessment and Referral for Care (SPARC): a survey of self-help support groups in health care

Sheffield Profile for Assessment and Referral for Care (SPARC) was developed in response to concerns that palliative care may not be reaching all people who could benefit from it. Acceptability of the tool is an important step in developing its future use.

Social Policy and Care of Older People at the End of Life

Providing care for older people at the end of life is an urgent public health issue (Seymour, 2012). As populations in many countries (including England and Wales) continue to age, death rates are also increasing with larger numbers of people dying in late old age (Gomes et al., 2011). As individuals live longer they often experience protracted periods of ill-health and develop multiple health conditions (co-morbidities). This is particularly the case for the growing numbers of older people who are the primary focus of this chapter. We concentrate on the experiences of the oldest old because, although it is important that end-of-life care (EOLC) fulfils the needs of dying people from all age groups, for individuals in their ‘Fourth Age’ of life (that is 85 years and over) the dying process is often complicated by the co-morbidities many experience. Dying can be highly unpredictable involving a series of peaks and troughs, with an older person becoming increasing frail during an often slow, dwindling decline (Nicholson and Hockley, 2011).

Changing technologies of cancer pain relief: case studies of innovation

In a previous article (1), we presented the first phase of a project within the International Observatory on End of Life Care that is seeking to develop an analysis of the specific problem of cancer pain relief in its historical and cultural context (2). We offered a historical overview of major themes in cancer pain relief in the 20th century by exploring the interplay of regulatory, scientific, clinical, cultural and ethical dimensions – themes which continue to shape contemporary debate and practice. In this article, we present an overview of the second phase of the study in which we explore contemporary debate and practice in case studies of three fields of innovation that emerged from our earlier analysis of the history of cancer pain relief since 1945.

OA19 Can oral history in palliative care influence the well-being of participants and the bereaved?

Background Oral history is the audio recording of unique life experience. Participants are involved in producing their own life histories, in their own voice, with no medical agenda. Oral history in palliative care began as a service in Sheffield in 2007 with Sheffield Hospitals Charity. In 2012 Macmillan Cancer Support piloted five further services in the North of England and Northern Ireland. Aim To assess the impact of recording an oral history in palliative care and to understand how the recording is received by family in bereavement. Methods The study conducted semi-structured interviews with people associated with oral history in Sheffield. Thirty two interviews were carried out with 10 patients; 9 bereaved family members; 6 health and social care professional; 7 bereavement support volunteers. Results People who had made recordings said that it was an enjoyable experience and that creating a family record was important to them. Bereaved family and friends stressed that having a voice recording was important for them and a comfort to listen to. The process of making the recording brought families together to share memories and find connexions and meanings. Conclusion Oral history interviewees, their family, bereavement volunteers and health professionals were enthusiastic about oral history. The research highlighted that creating a personal voice legacy can be an act of caring by the dying person, to help families subsequently cope with loss. The oral history process is seen as positive for the well-being of individuals in palliative care and bereaved family and friends.