ORIGINAL PAPERS. Quality of Life Assessment of Patients Under Stationary Palliative Care

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1 ORIGINAL PAPERS Piel. Zdr. Publ. 2015, 5, 1, 5 9 ISSN Copyright by Wroclaw Medical University Izabella Uchmanowicz 1 A, E, F, Aleksandra Kołtuniuk 2 C, D, E, Magdalena Ryznar 1 B, C, Joanna Rosińczuk 2 E, F Quality of Life Assessment of Patients Under Stationary Palliative Care Ocena jakości życia pacjentów objętych stacjonarną opieką paliatywną 1 Internal Nursing Department, Faculty of Clinical Nursing of the Health Science Department, Wroclaw Medical University, Wrocław, Poland 2 Department of Nervous System Diseases, Faculty of Clinical Nursing of the Health Science Department, Wroclaw Medical University, Wrocław, Poland A research concept and design; B collection and/or assembly of data; C data analysis and interpretation; D writing the article; E critical revision of the article; F final approval of article Abstract Background. Malignant neoplasm is a very serious health problem of Polish society. People for whom the therapeutic abilities of the treatment of neoplastic disease or other chronic, progressive and poorly prognostic disease have run out should be covered by home or stationary palliative care. Objectives. A quality of life assessment of patients under stationary palliative care. Material and Methods. The study was conducted in 2011 among 50 patients staying in the Brothers Hospitallers of St. John of God Hospice in Wroclaw. An SF-36 questionnaire, Beck Depression Inventory, Visual Analogue Scale (VAS) and original survey questionnaire were used in the research. The data obtained underwent statistical analysis. Results. Analysis of the research material has revealed that: the quality of life in the domain of physical fitness in patients staying 2 weeks in hospice is significantly lower in comparison to the level they had at the moment of being admitted to hospice; patients after a two-week stay in hospice evaluate their general mental state much worse depression level is much more intensive (p = ); after a two-week stay in hospice, respondents feel lower pain intensity than at the moment of admission. Conclusions. Patients staying for two weeks in hospice evaluate their general mental state much worse in comparison to the state at the moment of admission to hospice. During their stay in hospice, the quality of life in the domain of physical fitness deteriorated. During their stay in hospice, pain decreased which probably is connected with a better assessment of pain intensity and access to alleviating agents (Piel. Zdr. Publ. 2015, 5, 1, 5 9). Key words: quality of life, palliative care, patient. Streszczenie Wprowadzenie. Nowotwory złośliwe są bardzo poważnym problemem zdrowotnym polskiego społeczeństwa. Osoby, u których wyczerpały się możliwości terapeutyczne leczenia choroby nowotworowej lub innej przewlekłej, postępującej i źle rokującej choroby powinny zostać objęte domową lub stacjonarną opieką paliatywną. Cel pracy. Ocena jakości życia pacjentów objętych stacjonarną opieką paliatywną. Materiał i metody. Badanie przeprowadzono w 2011 r. wśród 50 chorych przebywających w Hospicjum Bonifratrów Św. Jana Bożego we Wrocławiu. W badaniu wykorzystano kwestionariusz SF-36, Skalę Depresji Becka, skalę wzrokowo-anologową VAS oraz autorski kwestionariusz ankiety. Uzyskane dane poddano analizie statystycznej. Wyniki. Analiza materiału badawczego wykazała, że: jakość życia w domenie sprawność fizyczna u pacjentów przebywających 2 tygodnie w hospicjum jest zdecydowanie niższa w porównaniu z jakością życia respondentów w chwili przyjęcia do hospicjum; pacjenci po 2 tygodniach pobytu w hospicjum znacznie gorzej oceniają swoje samopoczucie psychiczne depresja jest znacznie bardziej nasilona (p = 0,000337); po 2 tygodniach pobytu w hospicjum ankietowani odczuwają mniejsze natężenie bólu niż w chwili przyjęcia.

2 6 I. Uchmanowicz et al. Wnioski. Pacjenci przebywający 2 tygodnie w hospicjum istotnie gorzej oceniają swoje samopoczucie psychiczne w porównaniu ze stanem w chwili przyjęcia do hospicjum. W czasie pobytu w hospicjum jakość życia w domenie sprawność fizyczna pogorszyła się. Podczas pobytu w hospicjum dolegliwości bólowe zmniejszyły się, co ma prawdopodobnie związek z lepszą oceną natężenia bólu i dostępnością do środków przeciwbólowych (Piel. Zdr. Publ. 2015, 5, 1, 5 9). Słowa kluczowe: jakość życia, opieka paliatywna, pacjent. Malignant neoplasm is a very serious health problem of Polish society due to the progressive increase of new incidences. Since the beginning of the 21 st century there have been over 120,000 new cases, while in 2009 there were nearly 136,000, i.e. over 11,000 more than in In 2009, the incidence rate was 356 new incidences per 100,000 population while at the beginning of the decade (in 2000) there were 299, that is 57 fewer cases [1]. Unfortunately, most neoplasms are diagnosed at an advanced stage when effective treatment is already limited. Persons for whom the therapeutic possibilities of treatment of neoplasm or other chronic, progressive and poorly prognostic disease have run out should be covered by home or stationary palliative care. Palliative care consists of integrated actions of an interdisciplinary team consisting of doctors, nurses, physiotherapists, psychologists, priests and volunteers whose aim is to diagnose and satisfy the biological (e.g. pain alleviation, controlling troublesome disease symptoms, e.g. constipation), psychosocial and spiritual needs of patients suffering from chronic, progressive diseases, e.g. an advanced form of neoplastic disease [2]. Due to the minimal therapeutic abilities possible at the terminal stage of the disease, the actions of medical institution employees should be oriented at increasing the quality of life of incurable patients [2, 3]. A quality of life assessment of palliative patients is used for measuring the efficiency of symptomatic treatment and outlining the most important goals of patient care in the last moments of their lives [4]. Because of that, it is a more and more common tool in work with terminally ill patients. The aim of the study was the assessment of the quality of life of patients under stationary palliative care. Material and Methods The study was carried out in 2011 among 50 patients staying in the Brothers Hospitallers of St. John of God Hospice, Non-public Health Care Institution, situated in Poświęcka 8a in Wrocław. Patients were examined immediately after admission to the hospice and then after two weeks of stay. All persons participating in the study were informed about the goal, the course of the study and gave their conscious consent to take part in it. Consent for conducting the research was given by the Bioethics Commission at Wroclaw Medical University. For quality of life assessment, an original demographic and social survey was used in which questions were asked about: sex (female, male), age (under 35, 35 45, 45 55, 55 65, over 65), place of residence (country, city) and marital status (single, in a relationship). HRQoL assessment was made on the basis of a specific questionnaire, the SF-36 (Short Form Health Survey), which due to administering criterion belongs to methods of self-evaluation. The questions included in this questionnaire made it possible to assess eight domains of quality of life: physical functioning, limitations in performing duties due to physical health, pains, general feeling of health, vitality, social functioning, limitations in performing duties resulting from emotional problems, feeling of mental health. According to the Polish version questionnaire, obtaining high value scores means the lowest degree of the quality of life assessment, whereas the lowest value score means the highest level of quality of life [5]. In the study, other research tools were used as well, i.e.: Beck Depression Inventory (BDI), which is used in depression diagnostics. This scale consists of twenty one questions that the patient answers on his/her own. Four variants of response are possible which, depending on a given answer, are differently evaluated: scores 0 3, where 0 is the total absence of the symptom and 3 is the maximum intensity. VAS scale Visual Analogue Scale, is a numerical scale with graphical 10 cm segments on which the patient marks the degree of pain intensity he/she is currently experiencing. On the two ends of the segment there are two extreme pain evaluations: score 0 means no pain, whereas 10 is the maximum pain the patient can even imagine. Along the scale there can be verbal definitions of pain (mild, average, severe).

3 Quality of Life Assessment of Patients Under Stationary Palliative Care 7 The demographic data of the group of respondents was analyzed with the use of methods of descriptive statistics. The statistical data analysis was performed with the use of the Statistica 8 program and a Student s t-test with significance level p < Results Among the respondents, the largest group were females (64%), married people (66%) and inhabitants of urban areas (94%). The mean age of the examined population was On the basis of the research material analysis received from the SF-36 questionnaire, the following results were obtained. The quality of life in the domain of physical fitness in patients staying two weeks in hospice is significantly lower in comparison with the level they had at the moment of admittance to the hospice (p value is practically equal to 0). Both in males and females, a significant deterioration of the results in that domain was noticed after a two-week stay in the hospice. Moreover, in all age groups, the decrease of quality of life in the physical fitness domain was observed after two weeks of stay. These differences are statistically significant. Among the patients having stayed two weeks in the hospice, in the domain of limitation in performing duties due to physical health, a decrease of quality of life was observed in females, single persons and in the age bracket However, these differences were not statistically significant. On the other hand, in males, an increase of quality of life in that domain was noticed after two weeks stay in the hospice, however that difference was also not statistically significant. In the other domains, i.e. pains, general feeling of health, vitality, social functioning, limitations in performing duties resulting from emotional problems and feeling of mental health, no differences were recorded i.e. the quality of life of terminally ill patients did not improve or deteriorate after two weeks stay in the hospice. An analysis of research material concerning the patients mental state and depression level revealed that: while being admitting to the hospice, a worse mental state was declared by males and single persons; patients after a two-week stay in the hospice evaluated their general mental state much worse depression level is much more intensified (p = ); depression intensified after admission to the hospice in the group of both females and males, however only in the group of females was it a statistically significant difference (p = ); general mental state after a two-week stay in the hospice is evaluated as much worse by patients in the age bracket (p = ) and over 65 (p = ); both single people and those in relationships feel a mood decline after a two-week stay in the hospice (p = vs. p = ). An analysis of the data obtained from the Visual Analogue Scale indicated that patients while being admitted to the hospice evaluated the level of pain felt on average Most of all, pain was disturbing in the functioning of males, people under 35, people in relationships and those living in rural areas. After a two-week stay in the hospice the respondents feel lesser pain intensification than at the moment of admission (average level of 3.48). This difference is statistically significant. Detailed data is presented in Table 1. Discussion Depression is one of the most common ailments diagnosed among oncology patients, particularly at the terminal stage of the disease. It is estimated that in about 20% to 30% of patients suffering from neoplasms, at least once during the disease duration, symptoms indicating depression will appear [6]. Our own studies have shown that males and single persons declared a worse general mental state while being admitted to the hospice; whereas after a two-week stay in the hospice, depression deepened in females, both in single people and married ones, as well as among people over 55. According to Mystakidou s research, among oncology patients, more intense depression is characteristic of females and single persons [7]. Moreover, Nowicki et al. stated that depression intensification was greater among single patients [8]. A study by Modlińska et al. revealed a significant influence of the physical domain in shaping the general assessment of quality of life among people of advanced age in the terminal stage of neoplastic disease [9]. Our own studies show that during their stay in the hospice, the quality of life of the respondents in the physical fitness domain decreased, which can prove the still deteriorating health state of the patients. Also, Leppert confirms the decrease of quality of life in the physical fitness domain among patients included in stationary palliative care [10]. Pain, in accordance with the definition of the International Association for the Study of Pain (IASP), is a subjective feeling, unpleasant, sensual and emotional, associated with currently occur-

4 8 I. Uchmanowicz et al. Table 1. Analysis of the values of pain level measured using the Visual Analogue Scale (VAS) while being admitted to the hospice and after 2 weeks stay vs. sociodemographic data Tabela 1. Analiza wartości poziomu bólu mierzona skalą VAS w chwili przyjęcia do hospicjum oraz po 2 tygodniach pobytu a dane socjodemograficzne Mean Standard deviation p VAS 1 (while being admitted) VAS 2 (after 2 week stay) VAS 1 females VAS 2 females VAS 1 males VAS 2 males VAS 1 single persons VAS 2 single persons VAS 1 persons in a relationship VAS 2 persons in a relationship VAS 1 persons aged < VAS 2 persons aged < VAS 1 persons aged NS * VAS 2 persons aged VAS 1 persons aged NS VAS 2 persons aged VAS 1 persons aged VAS 2 persons aged VAS 1 persons aged > VAS 2 persons aged > NS * statistically insignificant. ring or potential tissue damage or described in categories of such damage [11]. An appropriate pain evaluation is the basis of its good and effective pharmacotherapy. The frequency of pain occurrence increases along with disease progression; in people of advanced age, it is estimated at 70 90%, therefore a properly conducted analgesic therapy is so important [12]. A study by Tereet et al. shows that geriatric patients treated for oncological reasons feel pain intensification at a level < 5 [13]. A study by Jasińska et al. revealed that pain is an important factor which negatively affects the general evaluation of quality of life of terminally ill patients hospitalized in the Palliative Medicine Department [4]. An analysis of the data obtained using the VAS scale proved that patients after a two-week stay in the hospice feel lesser pain intensification than at the moment of admission. Also, Janecki et al. observed that patients under stationary palliative care after 7 days of hospitalization feel significantly lower pain level [12]. Contrarily, according to Leppert, patients under stationary palliative care complained about a higher level of pain experienced during their second visit [14]. Conclusions Patients staying two weeks in the hospice evaluate their general mental state as much worse in comparison to their state at the moment of admission to the hospice. During the stay in the hospice, the quality of life in the domain of physical fitness deteriorated. During the stay in the hospice, pain decreased, which probably is connected with a better assessment of pain intensity and access to alleviating agents. References [1] Zdrowie i ochrona zdrowia w 2011 r. Główny Urząd Statystyczny, Warszawa 2012, 63. [2] Łuczak J., Kotlińska-Lemieszek A.: Opieka paliatywna/hospicyjna/medycyna paliatywna. Now. Lek. 2011, 80(1), 3 15.

5 Quality of Life Assessment of Patients Under Stationary Palliative Care 9 [3] De Walden-Gałuszko K., Majkowicz M.: Jakość życia w chorobach nowotworowych. Wydawnictwo Uniwersytetu Gdańskiego, Gdańsk 1994, 27. [4] Jasińska M., Tracz M., Kurczewska U., Orszulak-Michalak D.: Assessment of change of quality of life in hospitalized terminally ill cancer patients. Współcz. Onkol. 2010, 14(5), [5] Tylka J., Piotrowicz R.: Kwestionariusz oceny jakości życia SF-36 wersja polska. Kardiol. Pol. 2009, 67, [6] Zabora J., BrintzenhofeSzoc K., Cubow B., Hooker C., Piantadosi S.: The prevalence of psychological distress by cancer site. Psychooncology 2001, 10(1), [7] Mystakidou K., Tsilika E., Parpa E., Smyrniotis V., Galanos A., Vlahos L.: Beck Depression Inventory: exploring its psychometric properties in a palliative care population of advanced cancer patients. Eur. J. Cancer Care 2007, 16, [8] Nowicki A., Rządkowska B.: Depresja i lęk u chorych z nowotworami złośliwymi. Współcz. Onkol. 2005, 9(9), [9] Modlińska A., Buss T., Krakowiak P.: Ocena jakości życia osób w wieku podeszłym w terminalnym okresie choroby nowotworowej. Przegl. Lek. 2009, 66(9), [10] Leppert W.: Jakość życia chorych na zaawansowanego raka płuca objętych opieką paliatywną stacjonarną i domową. Med. Paliat. 2010, 1, [11] Korzeniowska K., Szałek E.: Ból. Farm. Współcz. 2010, 3, [12] Janecki M., Janecka J.: Behawioralna ocena bólu pacjentów z zaawansowaną chorobą nowotworową objętych stacjonarną opieką paliatywną. Med. Paliat. 2009, 1, [13] Terret C., Pérol D., Albrand G., Droz J.P.: Quality of life in geriatric oncology An evaluation of standard questionnaires in elderly men with urological malignancies. Critical Reviews in Oncology/Hematology 2001, 77, [14] Leppert W.: Ocena objawów u chorych na zaawansowanego raka płuca w opiece paliatywnej stacjonarnej i domowej. Med. Paliat. 2010, 2, Address for correspondence: Joanna Rosińczuk Department of Nervous System Diseases Faculty of Clinical Nursing of the Health Science Department Wroclaw Medical University K. Bartla Wrocław Tel.: joanna.rosinczuk@umed.wroc.pl Conflict of interest: None declared Received: Revised: Accepted: Praca wpłynęła do Redakcji: r. Po recenzji: r. Zaakceptowano do druku: r.