A PRE EXPERIMENTAL STUDY TO ASSESS THE

EFFECTIVENESS OF STRUCTURED TEACHING

PROGRAMME ON KNOWLEDGE REGARDING
PALLIATIVE TREATMENT AMONG CARE GIVERS OF
CANCER PATIENTS AT SELECTED HOSPITALS,
JALANDHAR, PUNJAB, 2015.

A synopsis

Submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING

Medical Surgical Nursing

Of

Baba Farid University of Health Sciences,

Faridkot, Punjab

2014

Meenakshi

M H R DAV INSTITUTE OF NURSING, JALANDHAR

 A PRE EXPERIMENTAL STUDY TO ASSESS THE
EFFECTIVENESS OF STRUCTURED TEACHING
PROGRAMME ON KNOWLEDGE REGARDING
PALLIATIVE TREATMENT AMONG CARE GIVERS OF
CANCER PATIENTS AT SELECTED HOSPITALS,
JALANDHAR, PUNJAB, 2015.

A synopsis

Submitted for the partial fulfillment of the requirement for the degree of

MASTER OF SCIENCE IN NURSING

Medical Surgical Nursing

Of

Baba Farid University of Health Sciences,

Faridkot, Punjab

2014

Meenakshi

Name & Signature Name & Signature

Of Supervisor of Co-Supervisor
Mrs. Veena Williams Ms. Salin.S
Prof. cum Principal Lecturer
Medical Surgical Nursing Medical Surgical Nursing

M H R DAV INSTITUTE OF NURSING, JALANDHAR

 SYNOPSIS OF THE STUDY

STATEMENT OF A Pre experimental study to assess the effectiveness of

THE PROBLEM structured teaching programme on knowledge regarding
palliative treatment among care givers of cancer patients at
selected hospitals, Jalandhar, Punjab, 2015.

SUPERVISOR Mrs. Veena Williams

Professor cum Principal M.Sc (Nursing) Medical Surgical
Nursing Pursuing Ph. D.
M H R DAV Institute of Nursing, Jalandhar.

CO-SUPERVISOR Ms. Salin. S

Lecturer M.sc (Nursing) Medical Surgical Nursing
M H R DAV Institute of Nursing, Jalandhar.

SUBMITTED BY Meenakshi
M.Sc. Nursing 1st Year
Medical Surgical Nursing
M H R DAV Institute of Nursing, Jalandhar.
 ABSTRACT OF PLAN OF THESIS

TITLE A Pre experimental study to assess the effectiveness of structured

teaching programme on knowledge regarding palliative treatment
among care givers of cancer patients at selected hospitals,
Jalandhar, Punjab, 2015.
FOR THE DEGREE M.Sc. Nursing
OF Medical Surgical Nursing
NAME OF THE Meenakshi
CANDIDATE
SUPERVISOR Mrs. Veena Williams
Professor cum Principal M.Sc (Nursing) Medical Surgical Nursing
Pursuing Ph.D.
M H R DAV Institute of Nursing, Jalandhar.
CO-SUPERVISOR Ms. Salin.S
Lecturer M.Sc (Nursing) Medical Surgical Nursing
M H R DAV Institute of Nursing, Jalandhar.
INSTITUTION M H R DAV Institute of Nursing, Jalandhar.
UNIVERSITY Baba Farid University of Health Science, Faridkot,Punjab – 151203
ABSTRACT

Palliative care is an approach that improves the quality of life of patients and their
families facing the problems with cancer. This study will be under taken to assess the
effectiveness of structured teaching programme on knowledge regarding palliative
treatment among care givers of cancer patients. An experimental research approach
and pre-experimental research design will be used. The sample size will be 60 from
selected hospitals at Jalandhar. Before conducting study the researcher will get
permission from the hospitals authorities and written consent will taken from the
subjects who will be included in the study. A self structured questionnaire will be
distributed to the participants of the study with a request to answer the question will
be given to the sample before and after the teaching programme palliative treatment.
The collected data will be analyzed and interpreted by using descriptive and
inferential statistics.
 INDEX

SR. NO. CONTENT PAGE NO.

1. Chapter I: Background of the Study 1-8

1.1 Introduction 1-3
1.2 Need of Study 3-6
1.3 Research Problem 6
1.4 Aim of Study 6
1.5 Objectives 6-7
1.6 Operational Definitions 7
1.7 Hypotheses 8
1.8 Delimitations 8
2. Chapter II: Review of Literature 9-16
3. Chapter III: Methodology 17-19
3.1 Research Approach 17
3.2 Research Design 17
3.3 Research Setting 17
3.4 Target Population 17
3.5 Sample & Sampling Technique 17
3.6 Inclusion & Exclusion Criteria 18
3.7 Selection & Development of Tool 18
3.8 Description of Tool 18
3.9 Validity of Tool 18
3.10 Reliability of Tool 18
3.11 Pilot Study 19
3.12 Data Collection Procedure 19
3.13 Ethical Consideration 19
3.14 Plan of Data Analysis 19
3.15 Methodology Flowchart 20
4. References 21-22
5. Annexures
Annexure I - Permission Letter of MO, Civil Hospital,
Jalandhar
 Chapter – I: Background of the study

Even if we can’t be together in the end, I’m glad that you were a part of my life.
(Anonymous)

1.1 Introduction

The World Health Organization (2002)1 has defined palliative care as “an approach
that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness, through the prevention and relief of suffering
by means of early identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial and spiritual. Palliative care affirms life and
regards dying as a normal process; intends neither to hasten nor to postpone death
uses a team approach to address the needs of patients and their families, including
bereavement counseling if indicated”.

Berger AM (2009)2 Cancer-related fatigue (CRF) is one of the most common

symptoms experienced by patients with cancer. Patient-related barriers to fatigue
include reluctance to report fatigue, and beliefs that fatigue is inevitable, unimportant,
and untreatable. Professionals are unaware of the principles of fatigue assessment and
management, and may be unwilling to initiate discussion about fatigue with patients.
Documentation of fatigue assessment and management in the medical record is
lacking in most clinical settings. Lack of health care reimbursement for fatigue affects
the availability of medications, prescription practices, and referral patterns to
supportive care services.

Lanken PN (2008)3 Palliative care focuses on complex pain and symptom

management, communication about care goals, alignment of treatments with patient
values and preferences, transitional planning, and support for the family. Increasingly,
this type of care is seen as an essential component of comprehensive care for patients
with critical illness, including those receiving aggressive intensive care therapies.
Although prior literature has illuminated why palliative care should be integrated in
the intensive care unit (ICU) and which aspects of intensive care unit palliative care
could be improved, guidance on how this might be effectively accomplished in
practice remains limited. This article focuses on practical approaches to intensive care

1
unit palliative care, which extend across a spectrum that is defined at either end by
models we refer to as “consultative” and “integrative.” We describe key features of
these models, which can be combined; discuss their advantages and disadvantages;
provide examples of initiatives using the different models; address the process of
choosing an appropriate model; and review outcomes of effective integration of
palliative care in the intensive care unit setting.

According to Stjernswärd J (2007)4 Globally, 35 million people experience pain and

suffering caused by old age or by life-limiting conditions such as cancer, and other
chronic diseases. The lack of palliative care is therefore an urgent problem. Providing
palliative support globally is also likely to benefit the approximately 70 million
families or voluntary caregivers who are helping those affected. Developing countries
account for two-thirds of the global burden [of 35 million] and a high proportion of
patients in these areas are in the advanced stages of illness, with little chance of being
cured. Ideally, care should be provided from the moment a life-threatening illness is
diagnosed and be adapted to the increasing needs of patients and their families during
the progression of a disease, through to the terminal phase and, ultimately, death
advocated a worldwide initiative to promote pain relief, opioid availability and
palliative care. This project succeeded in increasing global awareness and led to the
development of world health organization guidelines on cancer pain, opioid
availability, symptom control and other aspects of palliative care. Has estimated that
80% of cancer patients experience pain during the terminal phase of their illness.

Kikule(2003)5 A global body of scientific knowledge on palliative care interventions

could be used to improve the quality of life, the process of dying, and the death of
sufferers, and their affected families. Within Uganda’s already over-stressed health
infrastructure, palliative care services have not been adequately scaled up. This is a
particularly challenging problem for, as Kikule (2003) has argued, 58% of the
terminally ill require pain relief or other symptom control. In addition, 30% suffer a
loss of income, 5% need counseling support, and 7% require other support such as
spiritual help. Kikule suggests that a good death “occurs at home, in the absence of
pain and other distressing symptoms, without stigma or a sense of dependence, and
with adequate finances for the basic needs.”

2
Yuen KJ(2003)6 Palliative care is a holistic care which fulfills the requirements of
chronically ill patients. Those who need continued supportive care spend their lives
not in the hospital, but in the community among their family and neighbors. Hence,
the community has a major role in the care of these individuals. “Palliative care at
home: general practitioners working with palliative care teams” stated that home care
was the preferred option for most people with a terminal illness, and providing home
care relies on good community-based services, a general practice workforce
competent in palliative care practice, and willing to accommodate patients’ need.

McCorkle R(2001)7 “Palliative care provides relief from pain and other distressing
symptoms, affirms life and regards dying as a normal process, and intends neither to
hasten nor to prolong death. Palliative care integrates the psychological and spiritual
aspects of patient care and offers a support system to help patients live as actively as
possible until death. It also offers a support system to help the family cope during the
patient's illness and in their own bereavements.” Using a team approach, palliative
care addresses the needs of patients and their families, including bereavement
counseling if necessary. Changing patterns of the care of terminally ill people and
preference for death at home means there is often a heavy reliance on family
caregivers to provide the majority of the care needed.

1.2 Need of the study

J Muttapppallymyalil (2010)8 Studies have shown that many care givers are available
in the hospital with the patients to care them but still they do not have the adequate
knowledge and positive attitude in providing the care. It is important for the care
givers to learn and understand the importance of those palliative care and needs,
which are essential for the patients to be provided. They can clarify these doubts from
the nurse so that they can reach the expectations of the patients.

Thorpe KE (2006)9 Studies demonstrate that patients with a serious illness and their
families receive poor-quality medical care, characterized by untreated symptoms,
unmet psychosocial and personal care needs, a great burden for the caregiver, and low
patient and family satisfaction. Of the $491 billion spent by Medicare in 2009, 27

3
percent ($132.5 billion) was spent on acute care (hospital) services and a small
proportion 10 percent of the sickest Medicare beneficiaries accounted for about 57
percent of total program spending, which was more than $44,220 per capita per year.
The costliest beneficiaries include those using hospital services, those with multiple
chronic conditions or functional dependencies, those with dual eligibility for
Medicare and Medicaid, and those in their last year of life all of whom are the
appropriate target population for palliative care and, when eligible, hospice services .
Palliative care and hospice programs demonstrably improve physical and
psychosocial symptoms, family caregiver well-being, bereavement outcomes, and
patient, family, and physician satisfaction Palliative care and hospice teams meet
often with patients and their families to establish appropriate and realistic goals,
support families in crisis, and plan for safe transitions out of hospitals to more
supportive settings (home care, home hospice, nursing home care with hospice, or
inpatient hospice care).

Shanmugasundaram S (2006)10 Educating people in palliative care through programs

offered overseas can be useful in some instances, but it is not always an ideal solution.
The way forward is to draw on the existing, successful models that have been
described, to develop usable and dynamic educational initiatives within India itself,
from model palliative-care teaching centers attached to inpatient or community units,
thereby making close and relevant partnerships between theory and practice. The
centers for palliative care teaching should be culturally sensitive and relevant to the
Indian situation. Collaborations between the government of India, Indian Association
of Palliative care and world health organization provide further optimism regarding
future development. India has the potential to lead the way and enlighten others rather
than being subservient to those countries that enjoy resource wealth.

Peter Kirk (2004)11 A population revealed that the population of coverage of cancer
cases was 72% in Bangalore, and 78% in Mumbai the five year relative survival for
female breast cancer was 46.8% in Bangalore, 49.5% in Chennai and 55% in
Mumbai. The age adjusted incidence rate of esophageal cancer in women in
Bangalore is one of the highest (8.3 per 100000) in the world, in women cancer of the
cervix and breast together account for over 40% of the cancer in urban women and
65% of cancer in the rural registry in Barshi.
4
World health organization (2002)12 Worldwide there are over 10.9 million cases of
cancer. Each year 4.7 million are reported in developed countries and nearly 5.5
million are in the less developed countries. In developed countries cancer is 2nd most
common cause of death and epidemiological evidence points to emergence of a
similar trend is the developing country. Cancer is currently the cause of 12% of ill
death worldwide. Approximately 20 years time the number of deaths annually due to
cancer will increase from about 6 million to 10 million.

Parking DM (2002)13 Lung cancer has been the most common cancer worldwide.
Since 1985 and by 2012 accounted for 1.35 million new cases (12.4% of world total)
and 1.18 million deaths (17.6%) of world total. Although it is most frequent cancer in
men worldwide. Lung cancer is
Second to produce cancer incidence is developed countries. Breast cancer is by far the
most frequent cancer of women, accounting for 23% of all cancer because of its high
incidence and relatively good prognosis breast cancer is the most prevalent cancer in
the world, with an estimated 4.4 million women alive who have had the disease
diagnosed within the last 5 years composed to 1.4 million survivors men and women
from lung cancer.

Dr k Ramchandra Reddy (2002)14 In India the estimated number of new cancer per
year is about 7 lacks and over 3.5 lacks people die of cancer each year, out of these 7
lacks new cancer about 2.3 lacks (33%) cancer are tobacco related. The data for the
year 1996 showed a crude incidence rate (per 100000) in the metropolitan cities from
53.7 in Bangalore to 76.6 in Chennai among men and from 68.7 in Bangalore to 93.6
in Chennai among women. Using propensity score analysis to control for selection
bias, an estimated $2,300 is saved per hospice beneficiary on average, compared with
similar patients not receiving hospice services. Extrapolating this average savings
across the number of hospice patients served each year yields an overall savings of
more than $3.5 billion a year (1,560,000 patients ×$2,300 =$3.5 billion). The
maximum savings was reached with a length of hospice use of approximately seven
weeks, leading to reduced Medicare costs of $7,000 for cancer patients and $3,500 for
others. The savings attributed to hospice patients persisted for 233 days of hospice
care for cancer patients and 154 days of care for non cancer patients.

5
Dorothy R Marlow (2001)15 Palliative care means a medicine that gives temporary
relief from the symptoms of a disease but does not actually cure diseases .Palliative
cares are often used in the treatment of such diseases as cancer. An inadequate
medical and nursing workforce with expertise in palliative care is one of the greatest
barriers to access. A report commissioned by the Health Resources and Services
Administration (HRSA) in 2002 projected significant shortfalls in the nation's number
of palliative medicine specialists and called for a policy focused on increased
education and training in palliative medicine across all clinical specialties serving
patients with chronic and serious illness; expanded funding and reimbursement to
attract young physicians into the field; and examination of the appropriate role of non
physician professionals (such as nurse practitioners, clinical social workers, and
physician assistants) in strengthening access to palliative care across health care
settings.

As per Henderson’s definition of nursing in functional terms: "The unique function of

the nurse is to assist the individual, sick or well, in the performance of those activities
contributing to health or its recovery (or to a peaceful death) that he would perform
unaided if he had the necessary strength, will or knowledge. And to do this in such a
way as to help him gain independence as rapidly as possible. It is essential that every
patient, no matter how chronicity the disease may be, he or she must attain a peaceful
death. As cancer is one of the dreadful disease and there are not enough treatment
modalities for curing the disease especially in the 3rd and 4th stages of cancer.
Palliative treatment is one of the most essential treatments available for cancer
patients, so that they may have a peaceful death without pain and sufferings. There are
many voluntary agencies and nursing homes are providing palliative treatment for
patients with end stage of cancer. Certain patients are also taken care at home by
family members because during the end of life, patients are comfortable in their own
family surroundings. And when the cancer patient suffers with pain, the whole family
is in trouble. So it is essential that the care givers of cancer patients must have
adequate knowledge on palliative treatment among cancer patients. So there is a felt
need to assess the effectiveness of structured teaching programme on palliative
treatment among cancer patients.

6
1.3 Research problem
A Pre experimental study to assess the effectiveness of structured teaching
programme on knowledge regarding palliative treatment among care givers of cancer
patients at selected hospitals, Jalandhar, Punjab, 2015.

1.4 Aim of study

To assess the effectiveness of structured teaching programme on knowledge regarding

palliative treatment among care givers of cancer patients as it would aid the care
givers to provide better treatment for their loved ones at home or in community.

1.5 Objectives

 To assess the pre test knowledge regarding palliative treatment among care
givers of cancer patients.
 To develop and implement structured teaching programme on palliative
treatment to care givers of cancer patients.
 To assess the post test knowledge regarding palliative treatment among care
givers of cancer patients.
 To compare the pre test and post test knowledge regarding palliative treatment
among care givers of cancer patients.
 To find out the relationship between post test knowledge scores and selected
socio demographic variables.

1.6 Operational definitions

Assess: It is continuing process to examine outcome achievement among care givers

of cancer patients by structured teaching programme.

Effectiveness: It refers to significant gain in knowledge of care givers of cancer

patients regarding palliative treatment as determined by significant increase in post
test scores.

Structured teaching programme: It refers to the planned instruction which will be

given to educate the care givers of cancer patients regarding palliative treatment.

Knowledge: It refers to the subject’s correct response to questions on palliative

treatment as measured by self structured knowledge questionnaire.

7
Palliative treatment: It refers to the approach that improves the quality of life of
terminally ill cancer patients facing problems in pain management, dietary
management, psychological and spiritual problems.

Caregivers: Family member or close relatives in the age group of 20 to 50 years

staying and caring for the cancer patients.

Cancer patients: The patients suffering from 3rd and 4th stage of cancer such as
gastrointestinal cancer, Lung cancer, Oral cancer, Breast cancer, Brain tumor, Blood
cancer and cancer of cervix and admitted at selected hospitals, Jalandhar.

1.7 Hypotheses

H1- There will be significant increase in post test knowledge regarding palliative
treatment among care givers as assessed by self structured questionnaire significant at
p <0.05 level.

1.8 Delimitations

 Study will be limited to 60 care givers of patients in 3rd and 4th stage of cancer
only.
 Study will be limited to care givers of age group 20-50 years.

8
 Chapter- II: Review of Literature

A literature review helps to lay the foundation for the study and also inspire new
research ideas. A literature review provides readers with a background for
understanding current knowledge on a topic and illuminates the significance of the
new study. It assists in interpreting study findings and in developing implications and
recommendations.

2.1 Review of literature related to prevalence of cancer patients.

2.2 Review of literature related to knowledge on palliative treatment.
2.3 Review of literature related to effectiveness of palliative treatment in
prognosis of cancer patients.

2.1 Review of literature related to prevalence of cancer patients

Ulbricht Catherine (2011)16The aim of this study was to investigate the frequency of
complementary and alternative medicine complementary and alternative medicine
methods and clinical characteristics in cancer patients in southeast of Turkey. A total
of 324 patients (173 female) were enrolled to this study. Questionnaire was applied to
all patients individually for approximately 15 minutes by a doctor. At least one
complementary and alternative medicine method was used by 62% (n=201) of the
patients. 82.5% (n=166) of patients treated with complementary and alternative
medicine were using at least one herbal species. Likewise, 40.9% (68/166) of these
patients were using herbal mixtures and 39.8% (66/166) of them were using single
herbal as nettle (Urtica dioica) or its seed, 19.3 % (32/166) of them were using other
herbals. Complementary and alternative medicine methods were preferred more
frequently by the patients with metastatic stage (p=0.005), receiving palliative
treatment (p<0.001), chemotherapy (p=0.020), in between 40–60 ages patient groups
(p=0.002), and when duration of disease was lengthened (p=0.002). Complementary
and alternative medicine use among cancer patients is quite common. Presence of
metastatic cancer at diagnosis, receiving chemotherapy and palliative treatment and
long disease duration were found as main associated factors for complementary and
alternative medicine usage.

9
Arno P (2006)17 the number of families caring for individuals with progressive
disease will continue to increase as we face the care giving requirements of an aging
population. According to the National Survey of Families and Households, there were
in the united state almost 26 million informal caregivers; projections from the 2000
census suggest that the number is as high as 54 million. The average caregiver age in
this census was 46 years. More than 75% of family caregivers were women, 66%
were married, and 41% also reported having children under age 18 years living in the
home. Additionally, 64% of family caregivers indicated that they worked outside the
home; 52% of these caregivers were working full-time. Clearly, this large informal
caregivers’ group faces notable demands.

Tookman (2005)18 A Seventy-three participants completed one visit and 71

participants completed all study visits. There were no significant age, education or
gender differences between those that completed all visits versus those that dropped
out after one visit. Demographic information is presented. Statistical analyses were
performed on participants completing both visits. As expected, there was a significant
difference between the middle age and older adults for age (p<.05). However, there
was no significant difference between these groups for education or gender. Five
(15%) subjects in the older age group and three (9%) subjects in the middle age group
experienced vomiting that occurred between 1.5 – 2 hours post dose. This was
resolved with cold compresses on the forehead and ice chips and all subjects
completed study procedures despite the vomiting. There was a significant change in
reaction time over repeated assessments F (10, 57) = 6.50, p<0.01 with no significant
interaction effect with age or randomization order. This was due to a significant
increase in average reaction time (worse performance) one hour post dose compared
to baseline for simple and choice reaction time tasks for both middle age and older
adults (p<.01).

Angus Reid (2003)19 poll indicated that 90% of Canadians wish to remain in their own
homes, yet only 6% of caregivers feel they can adequately care for their loved ones
without hospice palliative care support. The preference for a home death is
compatible with many health funders’ aims to shift health care from institutions to the
community. As well, there is compelling evidence to indicate that home-based
10
palliative care is more cost-effective than hospital-based palliative care. However, it is
important to note that studies of the costs associated with the location of death have
not for the most part taken into account the indirect costs to the family in terms of
home care and lost income. Therefore, expectations and efforts to provide home-
based palliative care must take into account the financial strains on families and the
care giving burden that family member may experience, so that family caregiver
health is not compromised. Regardless of the palliative care service provided, the
family’s role as both caregiver and care recipient must be considered.

Fried O (2001)20 a palliative approach emphasizes supporting the choices of patients

and their families and has created some expectations regarding the patient’s choice to
die at home. The family’s ability to meet this request depends on family composition
and resources, their confidence in providing care, and access to appropriate care
support. It is estimated that between 50% and 70% of terminally ill patients prefer to
die at home in the comfort of familiar surroundings.

2.2 Review of literature related to knowledge on palliative treatment

Paul S(2013)21 The findings in this study indicated that while many members of the
public had heard of the concept of palliative care, there was a clear lack of familiarity
and awareness of what palliative care really means. A repeated theme, borne out in
this study, was the key influence of having a close friend or relative accessing
palliative care services upon increased awareness and familiarity with the concept and
services. There was a general tendency to identify palliative treatment goals in line
with pain relief to provide comfort and dignity at the end of life to elderly cancer
patients. Respondents emphasized the patient’s clinical needs. Yet this is in stark
contrast to the World Health Organization advocating that palliative care should not
only improve the quality of life for patients but also for their families, being available
from diagnosis regardless of condition or age. This is important to consider when set
against the backdrop that over the last decade in the United Kingdom, there has been
considerable government and media attention devoted to raising public awareness of
palliative care.

11
McCarthy J (2011)22 A community-based cross-sectional survey with a population of
3,557 individuals aged over 17 years was performed. Information was collected using
a structured questionnaire consisting of 17 items. Open questions were subject to
content analysis; closed questions were subject to descriptive statistics with inferential
testing as appropriate. A total of 600 responses were obtained (response rate 17%).
Responses indicated limited knowledge about palliative care. Female gender and
previous experience influenced awareness in a positive direction. Respondents who
worked in healthcare themselves or who had a close relative or friend who had used a
palliative care service were more aware of palliative care and the availability of
different palliative care services. Findings reveal the preferred place of care was the
family home. The main barriers to raising awareness were fear, lack of interaction
with health services and perception of lack of resources. A number of strategies to
enhance awareness, access and community involvement in palliative care were
suggested.

Cherny NI (2009)23 Between 2004 and 2009, we found a significant increase in the
frequency of occurrence for “palliative care” and “end-of-life,” but not for
“supportive care” or the other terms. We also found that “palliative care,” “end-of-
life” and “terminally ill” appeared more frequently in palliative care journals, while
“supportive care” and “best supportive care” were more often used in oncology
journals. Palliative care” and “hospice care” were most frequently defined, with a
definition found in 6% and 9% of articles that had at least one occurrence of each
term, respectively .We identified no definitions for “end-of-life” and “transition of
care,” and the rest of the terms were rarely defined (<5% of articles that used the
term,. Among all the articles that provided definitions for the 10 terms, we found only
two that focused on definitional issues lists definitions for the 10 terms . Among the
articles searched, we found a total of 16 different definitions for “palliative care” from
35 papers, with a majority of studies (21 of 35) that provided a definition for
“palliative care” adopting the one formulated by the World Health Organization. In
contrast, we found 13 different definitions for “hospice care” in 13 articles, and only
two definitions for “supportive care” from two articles. “Terminally ill” was described
as a prognosis of six months or less in four of five articles.

12
Webster R (2007)24 The Hospice Information Service website estimated that in 2005
there were hospice/palliative care services, either existing or under development, in
about 100 countries around the world with between 7000 and 8000 palliative care
initiatives including community based teams, inpatient units, and day care centers.
The distribution of these services is however, heavily weighted toward western
countries. Only about 6% of all palliative care services are located in Asia and Africa,
the regions where the majority of the world's population lives and dies. The data on
developing countries suggests that even in those countries where palliative care
services exist, the coverage of many of the programs is limited and palliative care is
not on the health agenda of their governments as a public health problem. This limits
the ability of palliative care services to impact on the populations that most need
them. The knowledge already exists about how to improve the quality of life of those
who are dying particularly in regard to pain relief, but it is not widely practiced. As
noted above, this is evident in developing countries and is partly attributable to the
usual reasons for poor health care of any description including poverty and lack of
basic needs (food, clothes, and clean water), lack of resources and inadequate health
system infrastructure. There are, however, three specific barriers to palliative care
implementation that are generally accepted as the major impediments: lack of
government commitment, opioid availability, and limited education.

Lilly CM (2000)25 Several initiatives have focused on improving the intensive care
unit performance of specific palliative care processes. For example, used an
“intensive communication intervention” involving pro-active family meetings within
72 hrs of admission intensive care unit for patients for whom the intensive care unit
attending physician predicted a length of intensive care unit stay >5 days, risk of
death >25%, or potentially irreversible change in function precluding eventual return
to home; meetings included the attending intensives, house staff, intensive care unit
nurse, family, and patient whenever possible. A before and after comparison showed a
1-day reduction in median length of intensive care unit stay for patients receiving this
intervention and shorter time to consensus about appropriate goals of care. A new
“bundle” of intensive care unit palliative care process measures provided the basis for
a large-scale performance improvement initiative by intensive care unit in the
Transformation of the intensive care unit Project by the Voluntary Hospital
Association, and for an ongoing initiative by intensive care unit in Veterans’
13
Integrated Service Network. Processes measured by this tool include identification of
the patient’s surrogate medical decision maker and resuscitation status; offers of
emotional, practical, and spiritual support; and an interdisciplinary family meeting to
discuss the patient’s condition, prognosis, and goals of care. Performance of these
care processes is evaluated by medical record documentation and is reviewed with
intensive care unit clinicians as feedback for performance improvement.

2.3 Review of literature related to effectiveness of palliative treatment in

prognosis of cancer patients

Carlson M (2010)26 the 47 percent growth in the number of hospice programs and the
74 percent increase in the number of persons served by hospice in the United States in
the last ten years have been equally dramatic. In 2009 there were 3,400 programs
(93% of which are Medicare certified) serving approximately 1.56 million Americans,
primarily in their homes (56% of days), nursing homes (29% of days), or assisted
living facilities (10.9% of days). In 2009 more than 40 percent of Medicare decedents
used hospice at some point in their care, an increase from 23 percent in 2000. More
than 80 percent of hospice beneficiaries are over age sixty-five, and more than one-
third are over eighty-five. In tandem with the aging of the hospice and U.S.
population, patterns of diagnosis have changed. Ten years ago the majority (53%) of
hospice patients died from cancer, while by 2008 only 31 percent had cancer and 69
percent died from chronic debilitating diseases such as frailty, atherosclerotic and
respiratory disease, and dementia, for whom the art and science of predicting
prognosis is considerably more uncertain . These shifts in diagnoses reflect a pattern
of hospice utilization increasingly correlated with the leading causes of death (cancer
accounts for fewer than 25% of deaths in the United States), suggesting that hospice
providers are responding to the needs of Medicare beneficiaries.

McCloskey SA (2007)27 of all respondents, 59% felt that they had adequate
knowledge to identify indications for palliative radiotherapy among their patients; the
other 41% responded “no” or “unsure.” Of respondents who had received palliative
care training, 67% were confident in their knowledge of palliative radiotherapy; only
56% of those who had not received palliative care training were confident in their
knowledge (p < 0.05). Shows knowledge of the effectiveness of palliative
14
radiotherapy for specific indications. “Very effective” was considered to be correct
for painful bone and soft-tissue metastasis, bleeding masses, and hemoptysis;
“somewhat” or “very effective” were considered correct for the remaining indications.
Knowledge of the effectiveness of palliative radiotherapy for bone metastasis, soft-
tissue metastasis, and dyspnea was considered adequate in 89%, 61%, and 80% of
respondents respectively. However, knowledge of palliative radiotherapy for bleeding
tumor masses and hemoptysis was considered adequate in only 40% and 22% of
respondents; 45% and 64% were unsure of the effectiveness of palliative radiotherapy
for those indications. Significant correlations were observed between referrals and
knowledge of radiotherapy indications. In the group of respondents that made
referrals for radiotherapy for bone metastasis, 98% demonstrated adequate knowledge
for that indication. However, among respondents who made no referrals for bone
metastasis, only 79% demonstrated adequate knowledge (p < 0.01). A positive
correlation was also found between limited knowledge about the use of palliative
radiotherapy for hemoptysis and bleeding tumour masses and the low utilization of
palliative radiotherapy for those indications (p < 0.01).

Morstad Boldt A (2006)28 among the 1213 articles found, 678 (56%) were from 2009.
“Palliative care” and “end-of-life” were the most frequently used terms. “Palliative
care,” “end-of-life” and “terminally ill” appeared more frequently in palliative care
journals, while “supportive care” and “best supportive care” were used more often in
oncology journals (P<0.001). Among 35 of 601 (6%) articles with a definition for
“palliative treatment,” there were 16 different variations (21 of 35 articles used the
World Health Organization definition). “Hospice care” had 13 definitions among 13
of 151 (9%) articles. “Supportive care” and other terms were rarely defined (less than
5% of articles that used the term).

Meghani SH (2004)29 Palliative treatment” and “hospice care” were most frequently
defined, with a definition found in 6% and 9% of articles that had at least one
occurrence of each term, respectively. We identified no definitions for “end-of-life”
and “transition of care,” and the rest of the terms were rarely defined (<5% of articles
that used the term, . Among all the articles that provided definitions for the 10 terms,
we found only two that focused on definitional issues lists definitions for the 10 terms
Among the articles searched, we found a total of 16 different definitions for
15
“palliative treatment” from 35 papers, with a majority of studies (21 of 35) that
provided a definition for “palliative care” adopting the one formulated by the World
Health Organization. In contrast, we found 13 different definitions for “hospice care”
in 13 articles, and only two definitions for “supportive care” from two articles.
“Terminally ill” was described as a prognosis of six months or less in four of five
articles.

Cassel JB (2002)30 this article examines data demonstrating the impact of the united
state health care system on clinical care outcomes and costs for the sickest and most
vulnerable patients. It also defines palliative care and hospice, synthesizes studies of
the outcomes of palliative care and hospice services, reviews variables predicting
access to palliative care and hospice services, and identifies those policy priorities
necessary to strengthen access to high-quality palliative care. Palliative care and
hospice services improve patient-centered outcomes such as pain, depression, and
other symptoms; patient and family satisfaction; and the receipt of care in the place
that the patient chooses. Some data suggest that, compared with the usual care,
palliative care prolongs life. By helping patients get the care they need to avoid
unnecessary emergency department and hospital stays and shifting the locus of care to
the home or community, palliative care and hospice reduce health care spending for
America's sickest and most costly patient populations. Policies focused on enhancing
the palliative care workforce, investing in the field's science base, and increasing the
availability of services in united state hospitals and nursing homes are needed to
ensure equitable access to optimal care for seriously ill patients and those with
multiple chronic conditions

16
 Chapter- III: Methodology

Methodology researches to controlled investigation of ways of obtaining, organizing

and analysis the data. It studies address the development, validation and evaluation of
research tool or technique.

3.1 Research approach

Experimental approach will be used in the study.

3.2 Research design

Pre experimental design (One group pre test, post test design) will be used to assess
the effectiveness of the structured teaching programme on knowledge regarding
palliative treatment among care givers of cancer patients.
O1 X O2
O1- Assessment of pre-test score by self structured questionnaire
X – Structured teaching programme
O2 – Assessment of post- test score by self structured questionnaire

3.3 Research Setting

The study will be conducted at selected hospitals, Jalandhar.

3.4 Target Population

Care givers of the cancer patients admitted at selected hospitals, Jalandhar.

3.5 Sample and Sampling technique

Purposive sampling technique will be used to select the sample for the study.

Sample size
The size of sample consists of 60 caregivers of cancer patients.

17
3.6 Inclusion and Exclusion criteria
Inclusion criteria

 Care givers of cancer patients in the age group of 20-50years.

 Care givers of cancer patients who can read Punjabi, English or Hindi.

Exclusion criteria

 Care givers not willing to participate in study.

Variables

Independent variables: Structured teaching programme on palliative treatment of

cancer patients.
Dependent variables: knowledge of caregivers regarding palliative treatment of
cancer patients.

3.7 Selection and development of tool

Tool will be developed after extensive review of literature and discussion with the
expert and guide.

3.8 Description of tool

The tool will consists of following parts:
Part- A Socio Demographic variables
Age, type of family, gender, monthly income, education, residential area, relationship
with patient, duration of illness, type of treatment.
Part- B Self structured questionnaire to assess the knowledge regarding palliative
treatment.
Part- C Structured teaching programme on palliative treatment of cancer patients.

3.9 Validity of tool

The validity of tool will be done by giving it to the experts in the field of Medical
Surgical Nursing. According to their valuable suggestions the tool will be modified.

18
3.10 Reliability of tool
The reliability of the tool will be assessed by Split half method and the reliability co-
efficient will be calculated by Spearman’s Brown Prophercy Formula.

3.11 Pilot study

Pilot study will be conducted on 10% of sample admitted at selected hospitals to
ensure the reliability and feasibility of the study.

3.12 Data collection procedure

Data will be collected from selected hospitals by questionnaire method. Prior to study
formal permission will be obtained from concerned authority. Further written consent
will be taken from care givers for their willingness to participate in the study and data
will be collected.

3.13 Ethical consideration

 Ethical clearance will be taken from the Ethical committee of M.H.R DAV
Institute of nursing, Jalandhar.
 Ethical clearance will be taken from the selected hospitals, Jalandhar.
 Written consent will be taken from the selected care givers at selected
hospitals before conducting the study.

3.14 Plan of data analysis

Analysis and Interpretation of data will be done by using descriptive and inferential
statistics.

19
 Flow Chart of Brief Outline of Research Methodology

Research Approach: Experimental Research Approach

Research Design: Pre-Experimental Research Design

One group pre-test post test group design O1 X O2

Target Population: Care givers of cancer patients at selected

hospitals, Jalandhar, Punjab

Sample: 60 care givers of cancer patients will be taken as sample

Sampling Technique: - Purposive sampling technique

Selection and Development of tool: Tool will be developed after

extensive review of literature and discussion with the experts and
guide

Description of tool: The tool consists of 3 parts:-

Part -A Socio- demographic variables

Part- B Self Structured questionnaire

Part- C Structured teaching programme on palliative treatment of

cancer

Data analysis and interpretation using descriptive and inferential

statistics

20
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