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Background: More people are dying at home with dementia and Alzheimer’s disease. While informal caregivers are the main providers of care for people with dementia dying at home, they require support from health and social care services. However, little is known about how they experience these services. Aim: To explore informal caregivers’ views and experiences of health and social care services when looking after a person with dementia at home at the end-of-life. Design: A qualitative interview study. Data were analysed using thematic analysis. Setting/Participants: Twenty-nine bereaved informal caregivers who had looked after a person with dementia at home during the last 6 months of life. Results: Specialist palliative care for people with dementia dying at home is rare and care is mostly managed by General Practitioners and domiciliary care workers. Four overarching themes were identified: Poor continuity of care; Lack of expertise; Limited advance care planning; and Loss of autonomy. Conclusions: End-of-life care at home for people with dementia must be proactively planned with an emphasis on advance care planning. Policy makers should recognise the critical role of domiciliary care services in end-of-life care and ensure that they are adequately qualified and trained.

Palliative care patients can be at risk of social isolation or loneliness. Interventions that can provide effective social support, and particularly emotional support, could facilitate healthy coping that bolsters quality of life and reduces depression in palliative care patients. This is an observational cohort study which recruited thirty patients (n = 30) from the day services of four independent hospices in England. Participants completed patient reported outcome measures in perceived social support, loneliness, and depression, at up to three time points. Age range was 56–91 years, males and females were equally represented, and the sample was 93% white British. In participants that provided two or more timepoints, perceived social support increased, and loneliness and depression decreased. Largest changes with the least variation between participants was in emotional support (p = 0.165) and loneliness (p = 0.104). These results suggest that the psychosocial patient reported outcome measures used (MOS-SS, UCLA, BEDS) could be sensitive to change aligned with the goals of this intervention in palliative care. Participants in this study were observed to derive psychosocial benefit from attending the hospice day service.

Peer mentors may offer distinctive forms of support to people with advanced cancer. Whilst peer mentor programmes are known, little is understood about recruiting and training peer mentors to support those with advanced cancer. The purpose of this study is to determine the feasibility of recruiting and training peer mentors for a novel peer mentor intervention to promote well-being in people with advanced cancer. Feasibility study testing proactive introduction to a trained peer mentor for 12 weeks in the context of a randomized controlled two-arm trial and nested qualitative process evaluation was used. Peer mentors have/had cancer, recruited via an open call. Two-day training included a new bespoke module on coping with cancer. Descriptive recruitment and training data were captured, supplemented by qualitative interviews, analysed thematically. Forty-eight people expressed interest, mostly female (69%), with breast cancer (32%), and recruited via social media (49%). Twelve people completed training, with attrition often due to availability or mentors’ own health; many had advanced cancer themselves. They wanted to ‘give something back’, but also formed supportive bonds with fellow mentors. It is feasible to recruit and train people with lived experience of cancer to be peer mentors, but those with particular characteristics may predominate. Broad social media based recruitment may have merit in widening the pool of potential peer mentors.

Purpose of reviewCognitive impairment is increasing in an ageing population and as people live longer, they are more likely to develop cancer therefore cognitive impairment and cancer are frequently co-occurring. We reviewed articles published since 2018 on cognitive impairment and cancer.Recent findingsThe current review has focused on diagnosis, treatment and palliative and end of life care. A comprehensive systematic review reported joint cancer and cognitive impairment prevalence from 0.2 to 45.6%. The review reported there was reduced likelihood of patients with co-occurring cognitive and cancer receiving information regarding cancer stage, reduced cancer treatment with curative intent and limited pain and symptom management. Further studies emphasized the role of family carers in supporting patients with cognitive impairment through cancer treatment.SummaryDisappointingly in an area where the numbers of patients with cognitive impairment and cancer are increasing, there appears to be little recently published research in this area. We conclude that further research is required to determine how best to support patients with cognitive impairment and cancer and families during diagnosis of cancer, treatment and continuing care and most importantly the findings of all studies are implemented within clinical practice.

There is a lack of robust evidence regarding outcomes for day care use among older people living with long-term conditions (LTCs). Day care is provided by independent, private and voluntary and charitable sectors. This systematic review aims to establish current evidence of outcomes for older people with LTCs attending day care services and outcomes on carers, across all service models. Narrative synthesis of quantitative and qualitative data was undertaken. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was carried out across eight electronic databases and reference lists of key journals between 2004 and October 2020 were searched. Searches returned 1,202 unique titles. Forty-five articles from 16 countries met the criteria on review of title, abstract and full article. There is limited evidence suggesting improved levels of perceived psychological health, quality of life, perceived general health, physical health and functioning for older people attending day care who have LTCs. The respite function of day care resulted in positive outcomes for carers. Studies evaluating outcomes for participants or carers were limited in quantity and quality. There is limited information regarding outcomes for day care attendance for older people with multiple LTCs from existing literature. Further research focusing on LTCs and day care attendance would benefit this field.

ObjectiveThis study sought to compare the Hospital Anxiety and Depression Subscale (HADS-D) and Brief Edinburgh Depression Scale (BEDS) as case-finding tools of major depressive disorder in patients with advanced cancer in a palliative care service.MethodsAn observational study was performed which included patients with advanced cancer who attended the palliative care service at the National Institute of Cancer in Mexico. Patients were asked to fill out the Hospital Anxiety and Depression Scale (HADS) and BEDS and were then assessed by a psychiatrist to evaluate major depressive disorder (MDD) as per the DSM-5 criteria. The case-finding capability of each scale was determined using receiver operating characteristic curves, assessing the area under the curve (AUC) in comparison to the clinical diagnosis.ResultsEighty-nine patients were included; median age was 57 years, and 71% were female. Among these, 19 patients were diagnosed with MDD during the interview. When comparing the self-reported scales, BEDS had a better performance compared with HADS-D (AUC 0.8541 vs. 0.7665). Limitations include a heterogeneous population and a limited sample size.Significance of resultsThe BEDS outperformed the HADS-D tool in discriminating patients with and without depression. A BEDS cutoff value of ≥5 is suggested as a case-finding score for depression in this population.

Background Advanced cancer affects people’s lives, often causing stress, anxiety and depression. Peer mentor interventions are used to address psychosocial concerns, but their outcomes and effect are not known. Our objective was to determine the feasibility of delivering and investigating a novel peer mentor intervention to promote and maintain psychological wellbeing in people with advanced cancer. Methods A mixed methods design incorporating a two-armed controlled trial (random allocation ratio 1:1) of a proactive peer mentor intervention plus usual care, vs. usual care alone, and a qualitative process evaluation. Peer mentors were recruited, trained, and matched with people with advanced cancer. Quantitative data assessed quality of life, coping styles, depression, social support and use of healthcare and other supports. Qualitative interviews probed experiences of the study and intervention. Results Peer mentor training and numbers (n = 12) met feasibility targets. Patient participants (n = 12, from 181 eligible who received an information pack) were not recruited to feasibility targets. Those who entered the study demonstrated that intervention delivery and data collection were feasible. Outcome data must be treated with extreme caution due to small numbers, but indicate that the intervention may have a positive effect on quality of life. Conclusions Peer mentor interventions are worthy of further study and researchers can learn from these feasibility data in planning participant recruitment and data collection strategies. Pragmatic trials, where the effectiveness of an intervention is tested in real-world routine practice, may be most appropriate. Peer mentor interventions may have merit in enabling survivors with advanced cancer cope with their disease. Trial Registration The trial was prospectively registered 13.6.2016: ISRCTN10276684.

Background: Most deaths occur in people over the age of 65 years, yet there is widespread evidence that older people have inequitable access to good palliative and end-of-life care. For people with dementia, there are further barriers to receiving palliative care. Identifying when older people with dementia are reaching the end of their lives is not straightforward. A palliative approach to care has been recognised as key in UK practice guidance; the National Institute of Health and Care Excellence recommends that, from diagnosis, people living with dementia should be offered flexible, needs-based palliative care that takes into account how unpredictable dementia progression can be. However there are still wide gaps in care in the dementia pathway, largely because commissioning is fragmented. Method: This paper describes the Admiral Nurse case management approach to palliative care by benchmarking its practice against the European Association of Palliative Care white paper recommendations for palliative care in dementia.

Purpose of reviewDementia is now recognized as a progressive life-limiting illness where many patients can benefit from access to palliative care.Recent findingsThe present review has focused on three areas namely, advanced care planning in supporting palliative care for dementia, hospice provision for people with dementia and provision of care within family home. In advanced care planning, there is little research on systematically developed and implemented advance care planning interventions or whether they achieve desired outcomes for end-of-life care. There is limited research on hospice-based care for patients with dementia and most studies are U.S. based. Equally studies exploring how family carers can be supported and facilitated to care at home for the person with dementia to the end of life are exploratory rather than determining what factors may be important.SummaryThere are relatively few studies, especially quantitative studies or intervention studies being carried out to determine most effective means of providing palliative care for people with dementia, particularly with respect to advanced care planning, the provision of hospice-based care and support at home. Despite increased public awareness of dementia as a terminal illness, more research is required to support patients with dementia and their families at the end of life.

Purpose of review For older people with long-term conditions, regular structured activities within a community setting meeting others are thought to improve well being and quality of life. Historically local authority-run day care centres were widely available, but austerity measures have meant that in many areas, such provision has been markedly reduced and different models of day care services are being developed. There is little known about outcomes of day care provision for older people with long-term conditions. Recent findings This review has critically examined the recent evidence on outcomes of day care provision for older people with long-term conditions and will focus on three areas – physical functioning, intergenerational provision and measurement of outcomes. In terms of interventions to improve physical functioning for older people with long-term conditions attending day care, there are few studies and it is difficult to generalize but there appears to be a trend for positive impact on physical functioning when activities are incorporated into a day care programme. There is a paucity of research on intergenerational provision, however, the small number of studies suggest positive benefits. Studies measuring outcomes for older people with long-term conditions attending day care services are very limited in terms of outcome data with the exception of a Canadian study, which suggested that attendance at day care could reduce hospital attendance and admissions. Summary This review reveals a lack of research of day care provision for older people with long-term conditions. There is a suggestion in the small number of articles included in this review that there can be benefits both in terms of global outcomes of attendance and in improved physical functioning; there is limited evidence of the value of intergenerational provision. Robust research with collection of meaningful outcomes is required to ensure that the increasing number of older people with long-term conditions are enabled to access high-quality day care provision.

ObjectiveDepression in palliative advanced cancer patients is common, but often goes unrecognized. One of the first steps toward improving detection is the development of tools that are valid in the specific language and setting in which they are to be used. The Brief Edinburgh Depression Scale (BEDS) is a sensitive case-finding tool for depression in advanced cancer patients that was developed in the United Kingdom. There are no validated instruments to identify depression in Mexican palliative patients. Our aim was to validate the Spanish-language version of the BEDS in Mexican population with advanced cancer.MethodWe conducted a cross-sectional study with outpatients from the palliative care unit at the Instituto Nacional de Cancerología in Mexico City. The Mexican BEDS was validated against a semistructured psychiatric clinical interview according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, classification criteria for major depressive disorder. The interviewer was blind to the BEDS score at the time of the assessment.ResultSeventy subjects completed the scale and interview. Women represented 71.4% of the sample and median age of subjects was 56.5 years (range, 20–85 years). The prevalence of major depressive disorder according to the psychiatric interview was 20%. The most valid cutoff for defining a case of depression was a score ≥5 of 18 on the Mexican BEDS, which gave a sensitivity of 85.7% and specificity of 62.5%. The scale's Cronbach's alpha was 0.71.Significance of resultsMajor depressive disorder is frequent in Mexican palliative patients. The Spanish-language Mexican version of the BEDS is the first valid case-finding tool in advanced cancer patients in this setting.

Purpose: To design and evaluate an intervention to address carers’ needs for practical information and support skills when caring for a person with cancer at end of life. Method: Phase I 29 carers were interviewed about need for practical information, support skills and their preferences for information delivery. The preferred format was a booklet. Phase 2 evaluated the booklet. 31 carers and 14 district nurses participated. Validated questionnaires: on perceptions of caregiving and carer health before and after the booklet was used and interviews with both carers and nurses were untertaken.24 carers completed both interviews. Quantitative data were coded using scale manuals and analysed using SPSSv20 and interview data was analysed thematically. Results: Carers were aged 31-82 and cared for people aged 50-92; 8 carers were male and 23 female; 20 cared for a partner, 8 for a parent and 1 for a sibling (2 undisclosed). Carers were positive about the booklet, however many carers would have liked the booklet earlier. Carers reported feeling more positive about caregiving, and more reassured and competent in their role. District nurses found the booklet useful and reported receiving fewer phone calls from study carers than others in similar situations. Conclusions: The booklet intervention was a source of reassurance to carers and it has the potential to be incorporated into everyday practice. The challenge is in when and how to distribute the booklet and more work is required on the timing of delivery in order to maximise the usefulness of booklet to carers.

© 2018 John Wiley & Sons Ltd. Individuals managing the challenges of life-limiting illness require adequate social support to maintain quality of life. Qualitative research reports that patients value highly the social support obtained in palliative care interventions such as day care and group therapies. This systematic review aims to summarise existing quantitative evidence on palliative care interventions that facilitate social support. Research literature was systematically searched using electronic databases and key journals. Searches returned a total of 6,247 unique titles of which sixteen were eligible for inclusion. Interventions include group therapies, group practical interventions and palliative day care. Outcome measures and study designs were heterogeneous. Only one study used a validated outcome measure of social support. Benefits were influenced by participant characteristics such as baseline distress. Partial economic evaluation was attempted by two studies. Methodological challenges include attrition and use of outcome measures that were insensitive to change. Statistically significant results were reported in psychological and physical domains. Evidence is limited due to methodological issues and a scarcity of quantitative research, particularly regarding long-term benefits and cost-effectiveness. Interventions may be more beneficial to some groups than others.

Palliative care for patients with dementia can be a challenge for clinicians where assessment of symptoms in patients who may not be able to express their needs is difficult and recognising that patients are entering the terminal phase complex. As academic clinicians we will discuss the current situation with a UK focus and review some of the recent research exploring palliative care for patients with dementia.

Background This study explored whether scores indicating depression on Patient Health Questionnaire 9 and patient reports of thoughts of self-harm were prognostic factors for survival in advanced cancer. Method Patients with advanced cancer were recruited into the study from palliative care day units and invited to complete measures for depression which included Patient Health Questionnaire 9, and Edinburgh Depression Scale at recruitment, and at 8, 16 and 24 weeks. Results 629 patients were recruited into the study; 139 (22%) died during 6 months follow up and 235 patients (37.4%) died during the study period. The age range of patients recruited was 21–94 years—mean age 66 years and 67% of patients recruited were female. The overall median survival of patients recruited was 37.1 weeks (95% CI 36.0, 39.9 weeks) (range 0–116 weeks). The estimated median survival time of patients whose baseline PHQ9≥9 was 36 weeks with 95% confidence interval of (31, 39) and for patients whose baseline PHQ9

Introduction:\ud A number of international guidelines have been developed to support primary care clinicians improve the quality of care for patients with chronic heart failure at the end of life. The objective of this study was to undertake a systematic evaluation of such guidelines in relation to end-of-life care.\ud \ud Methods:\ud A systematic literature search of research databases and guideline clearing houses was undertaken. The selected guidelines were independently assessed by two researchers using the AGREE II quality criteria. A data-extraction framework was devised based on the holistic needs assessment tool of the Gold Standards Framework. The content of each guideline was then analysed using an approach similar to that used for thematic analysis.\ud \ud Results:\ud A total of 19 guidelines were included. Those guidelines with lower overall AGREE II scores covered fewer domains on the holistic needs assessment. Across all guidelines the lowest scoring domain was applicability and stakeholder involvement. Qualitative assessment showed that some guidelines adopt an unwavering disease orientated approach to assessing patient need. Guidance around continuity of care, out of hours care and after care was particularly poor in several guidelines. There was considerable heterogeneity in the evidence presented even amongst those guidelines that achieved high AGREE II scores.\ud \ud Conclusion:\ud Combined quantitative and qualitative assessment demonstrates the importance of rigorous guideline development. Whilst the variation in evidence presented could be a result of methodological heterogeneity in the development of guidelines, it raises important questions about the processes by which evidence, information and knowledge become transformed into clinical guidelines.

Introduction A pilot trial was carried out to determine if a focussed narrative interview could alleviate the components of suffering and anxiety and depression in advanced cancer patients. Intervention Patients recruited were invited to participate in a focussed narrative interview and reflect on their perspectives on their sense of “meaning”, regarding suffering and their psychological, physical, social and spiritual well being – the emphasis was on allowing the patient to tell their story. Patients were encouraged to share what resources they themselves had utilised in addition to what professional care they may have received, to maintain a sense of well being. Method Patients with advanced metastatic disease were recruited from hospices in the North West of England – the only exclusion criteria were not being able to understand written and spoken English and a non cancer diagnosis. At recruitment patients were asked to complete a numerical scale for suffering; the Brief Edinburgh Depression Scale, Edmonton Symptom Assessment Scale (ESAS), FACIT Spiritual well being questionnaire, Demographic information was collected and patients were randomised to either the intervention arm of the trial or the usual care arm of the study. Patients in both groups were invited to complete each measure at 2, 4 and 8 weeks. Results One hundred people were recruited into the study – 49 were randomised to intervention group and 51 to control group. The median age of patients was 66 years age range (31–89 years) and 68% of patients were female. At baseline the ECOG performance of 75% of patients recruited was 1 or 2. The median survival of all patients in the study was 169.5 days (range 10 days to still alive at end of study). There was no significant difference at any timepoint in scores on suffering measure between intervention group and control group. At each time point the intervention demonstrated mean improvement in scores for depression and anxiety on ESAS – the greatest changes for both depression and anxiety were seen at 4 weeks. Conclusion This pilot randomised controlled trial of a focussed narrative intervention demonstrated an improvement in mean changes in scores for depression and anxiety at 2, 4, and 8 weeks. We suggest this intervention may have beneficial effects on depression and anxiety, but a larger powered trial is required to determine the full effects.

Summary Objective To explore the individual experiences of those who had experienced the death of a parent(s) before the age of 18, and investigate how such experiences were perceived to impact on adult life. Design An exploratory qualitative design using written (n = 5) and oral (n= 28) narratives and narrative analysis was adopted to explore the experiences 33 adults (7 men and 26 women) who had experienced parental death during childhood. Setting UK Participants Individuals living in the North West of England who had lost a parent(s) before the age of 18. Main outcome measures Views of adults bereaved of a parent before the age of 18 of impact of parental loss in adult life. Results While individual experiences of bereavement in childhood were unique and context bound, the narratives were organized around three common themes: disruptions and continuity, the role of social networks and affiliations and communication and the extent to which these dynamics mediated the bereavement experience and the subsequent impact on adult life. Specifically they illustrate how discontinuity (or continuity that does not meet the child's needs), a lack of appropriate social support for both the child and surviving parent and a failure to provide clear and honest information at appropriate time points relevant to the child's level of understanding was perceived to have a negative impact in adulthood with regards to trust, relationships, self-esteem, feeling of self-worth loneliness and isolation and the ability to express feelings. A model is suggested for identifying and supporting those that may be more vulnerable to less favourable outcomes in adult life. Conclusions The findings suggest that if the negative consequences are to be minimized it is crucial that guidelines for ‘best practice’ that recognize the complex nature of the bereavement experience are followed.

ObjectivesTo understand successful strategies used by people to cope well when living with advanced cancer; to explore how professionals can support effective coping strategies; to understand how to support development of effective coping strategies for patients and family carers.DesignQualitative serial (4-12 week intervals) interview study with people with advanced cancer and their informal carers followed by focus groups. The iterative design had a novel focus on positive coping strategies. Interview analysis focused on patients and carers as individuals and pairs, exploring multiple dimensions of their coping experiences. Focus group analysis explored strategies for intervention development. Participants26 people with advanced (stage 3-4) breast, prostate, lung or colorectal cancer, or in receipt of palliative care, and 24 paired nominated informal/family carers. SettingParticipants recruited through outpatient clinics at two tertiary cancer centres in Merseyside and Manchester, UK, between June 2012 and July 2013. Results45 patient and 41 carer interviews were conducted plus 4 focus groups (16 participants). People with advanced cancer and their informal/family carers develop coping strategies which enable effective management of psychological wellbeing. People draw from pre-diagnosis coping strategies, but these develop through responding to the experience of living with advanced cancer. Strategies include being realistic, indulgence, support, and learning from others, which enabled participants to regain a sense of wellbeing after emotional challenge. Learning from peers emerged as particularly important in promoting psychological wellbeing through the development of effective ‘everyday’, non-clinical coping strategies. ConclusionsOur findings challenge current models of providing psychological support for those with advanced cancer which focus on professional intervention. It is important to recognise, enable and support peoples’ own resources and coping strategies. Peer support may have potential, and could be a patient-centred, cost effective way of managing the needs of a growing population of those living with advanced cancer.

This study was conducted to explore the interrelationships among caregiver burden, emotional status and quality of life (QoL) in caregivers of lung cancer patients, and to identify whether caregiver burden and health status are associated with patient emotional status and QoL. Forty-three dyads of lung cancer patients and their caregivers were included for analysis. Caregiver-reported outcomes were measured by Caregiver Burden Scale (CBS), Caregivers Quality of Life Index-Cancer (CQOLC) and Hospital Anxiety and Depression Scale (HADS), while patient-reported outcomes were collected by HADS and Lung Cancer Symptom Scale (LCSS). The majority of the CBS and CQOLC scores were significantly higher in anxious and depressed caregivers than non-anxious and non-depressed caregivers (p < .01 or .05). Caregivers of depressed patients experienced significantly greater emotional distress than those of non-depressed patients (p < .01). Significantly positive associations were identified among most of the CBS, CQOLC and caregiver HADS scores. Patient LCSS scores were positively correlated with the CBS and caregiver HADS scores, and patient HADS scores were also positively related to caregiver HADS scores. The close interrelationships between caregiver and patient health outcomes provide evidence that lung cancer patients and their caregivers should be viewed as a unit in future supportive service models.

Background Spirituality is an important component of palliative care that is incorporated into practice and the subject of research. A literature review by the authors indicated that many studies into the spiritual needs of palliative care patients operationalised highly reductive constructs of spirituality and relied upon unexamined assumptions and concepts. Methods We examine the use of models as a strategy to explain how spirituality functions in the lives of patients and critically review examples of descriptive modelling and mathematical modelling. The explanatory and predictive potential of these techniques is considered along with methodological limitations in representing complex aspects of human nature in models. Proposal We propose a realistic synoptic model to explain how spirituality is lived and experienced in the wider context of a mental, personal and social world. We describe the essential conceptual apparatus and mechanisms of lived spirituality including beliefs, behaviour and experience, and we suggest that spirituality is a feature and capacity of the system as a whole. Conclusions The synoptic model provides an explanation of how spirituality operates in the totality of patients9 lives and aims to capture aspects of spirituality that remain neglected by researchers and practitioners. It is proposed as a corrective to reductionist approaches and supports the contribution of different disciplines and different ways of thinking about spirituality.

Context Spirituality is a distinctive subject within palliative care practice and literature, but research to date is relatively undeveloped in this field and studies often throw more light on conceptual and methodological issues than producing reliable data for clinical practice. Objectives To determine what is known about the spiritual needs of palliative care patients from the evidence presented in published research. Methods Specialist online databases were interrogated for primary empirical studies of patients with a chronic disease unresponsive to curative treatment. Studies that only used a proxy for the patient or reported expert opinion were excluded. Each study was critically appraised for quality and the strength of its evidence to determine if any data could be pooled. Results Thirty-five studies were identified, equating to a total of 1374 patients. Study populations were typically people with advanced-stage cancer, older than 60 years, who were English speaking, and with a Christian or Jewish religious affiliation, reflecting the predominance of Anglo-American studies. Studies fell into two groups: those that investigated the nature of spiritual experience and those that examined the relationship of spirituality with other phenomena. The evidence was insufficiently homogeneous to pool. Conclusion Relevant accounts of what spirituality means for palliative care patients and evidence of how it operates in the lives of people with life-limiting disease can be derived from research. Studies to date are limited by reductive representations of spirituality and the conduct of research by health professionals within health care communities demarcated from disciplines and interpretive traditions of spirituality.

Purpose Depression is one of the most common psychiatric diseases seen in patients with advanced cancer. It is not only an independent predictor of poor survival in advanced cancer but also reduces quality of life, reduces compliance with treatment and prolongs hospitalization. Yet all too often depression is under diagnosed and under treated in this population. Method A literature review was undertaken using extensive electronic and hand searches. Key findings Whilst it is true that the diagnostic and treatment challenges facing healthcare professionals in this area are considerable one must not forget that depression in advanced cancer is treatable and validated assessment tools have been developed to facilitate diagnosis. Conclusions This review article provides the reader with a comprehensive review of the current evidence in this field with particular focus on assessment and treatment. Depression is under diagnosed and under treated – there are valid screening and assessment tools available which will allow appropriate management of this important and debilitating symptom.

The objective of this study was to review the literature on depression in palliative cancer care in order to identify which assessment methods and classification systems have been used in studies of depression. Extensive electronic database searches in PubMed, CancerLit, CINAHL, PsychINFO, EMBASE and AgeLine as well as hand search were carried out. In the 202 included papers, 106 different assessment methods were used. Sixty-five of these were only used once. All together, the Hospital Anxiety and Depression Scale (HADS) was the most commonly used assessment method. However, there were regional differences and while the HADS dominated in Europe it was quite seldom used in Canada or in the USA. Few prevalence and intervention studies used assessment methods with an explicit reference to a diagnostic system. There were in total few case definitions of depression. Among these, the classifications were in general based on cut-off scores (77%) and not according to diagnostic systems. The full range of the DSM-IV diagnostic criteria was seldom assessed, i.e. less than one-third of the assessments in the review took into account the duration of symptoms and 18% assessed consequences and impact upon patient functioning. A diversity of assessment methods had been used. Few studies classified depression by referring to a diagnostic system or by using cut-off scores. Evidently, there is a need for a consensus on how to assess and conceptualize depression and related conditions in palliative care.

This paper reports finding from a nested qualitative study designed to elicit the views and perceptions of those who participated in a randomised controlled feasibility trial testing a non-pharmacological intervention, Respiratory Distress Symptom Intervention (RDSI), for the management of the breathlessness-cough-fatigue symptom cluster in lung cancer. Semistructured interviews were conducted with 11 lung cancer patients, three caregivers and seven researchers involved in recruitment, consent, RDSI training and delivery and participant follow-up. Thematic analysis identified key considerations including: theimportance of informed consent emphasising commitment to completion of paperwork and raising awareness of potential sensitivities relating to content of questionnaires; ensuring screening for the presence of symptoms reflects the language used by patients; appreciation of the commitment required from participants to learn intervention techniques and embed them as part of everyday life; conduct of interviews with patients who decline to participate;and conduct of serial interviews with those receiving RDSI to further inform its routine implementation into clinical practice. This study will inform the development of a fully powered follow-on trial testing the hypothesis that RDSI plus usual care is superior to usual care alone in the effective management of this symptom cluster in lung cancer.

This study explored how elderly people living in the community perceive issues around death, dying, and the end of life using a qualitative grounded theory approach. Forty individuals aged between 80 and 89 years who were living alone in the community were interviewed and were identified through purposive and random sampling. The results revealed that issues associated with end of life included fear of how they would die, fear of becoming a burden to others, wanting to prepare for and have a choice with regard to where and when they die, and issues relating to assisted dying. The study demonstrated that issues relating to the end of life are a major concern for older people, but are seldom addressed by professionals. Listening to and understanding the views and experiences of the older age group regarding end-of-life care is needed if adequate person-centered care is to be delivered to this ever-growing population group.

Background The development of a brief valid tool to screen for depression in patients with advanced cancer is important. This paper reports data on the psychometric properties of the Brief Edinburgh Depression Scale. Method Two hundred and forty six patients who fulfilled the inclusion criteria completed the 10-item EDS and Present State Examination. Results Factor extraction revealed 6 items from the ten item EDS. The most valid cut off for defining a case, using the PSE diagnosis as the “gold-standard”, was a score of 6 out of 18 on the Brief Edinburgh Depression Scale which gave a sensitivity of 72% and specificity of 83% with a PPV of 65.1% and NPV of 87.1%. Conclusions The six item EDS is a brief and sensitive method of screening for depression in advanced cancer patients — this novel use of the Edinburgh depression scale may have a significant impact on the assessment and thus management of this distressing symptom.

Patients newly diagnosed with inoperable lung cancer experience a symptom distress burden that may impact upon functional performance in daily activities. This structured review examines empirical evidence to see how functional limitation and rehabilitation needs are represented in the supportive care literature in this population. Early access to rehabilitation services may ameliorate the impact, but evidence of need following diagnosis is required.Electronic databases Medline, Web-of-Science, Cinahl, AMED and PsychINFO were searched in April 2014. Hawker's criteria were used to assess methodological quality. The World Health Organization International Classification for Functioning Disability and Health (WHO-ICF) guided framework analysis and narrative synthesis.Thirty-two articles selected for further analysis included heterogeneous studies exploring the following conceptually diverse dimensions: quality of life, symptoms, functional performance and unmet supportive care needs at diagnosis and first treatment phase. Studies, mostly utilising patient self-report measures, reveal functional impairments, limitations and restrictions influenced by personal and environmental factors across all WHO-ICF domains. Two studies included objective evaluations of function. Six studies explored functional performance as a primary aim. Five studies suggested specific or general rehabilitation interventions to address identified needs.Needs associated with a diagnosis of inoperable lung cancer impact on daily life in the peri and early post-diagnostic period across all WHO-ICF domains. Specific functional impairments, limitations and restrictions and the potential role of rehabilitation services are rarely explored objectively or discussed in the supportive care literature for this population. Research is needed to guide the development of effective rehabilitation interventions acceptable to patients, health care commissioners and providers that address the impact of a new lung cancer diagnosis on functional performance.

Background: There is an increasing international policy direction to promote home death for dying patients which will impact on the demands placed on family carers. The early identification of carer needs and appropriate intervention can help avoid crisis situations for the carer and avoidable hospital admissions which are reported to be a global concern. The aim of the study was to explore what professionals and carers of patients with cancer and advanced progressive illness, in their last year of life, find burdensome and to develop an alert system for use by non-specialist staff.\ud Methods: A mixed-method, multi-phased, consensus study sequentially utilising qualitative and quantitative data to develop and pilot the Carers’ Alert Thermometer (CAT). 245 people (117 carers and 128 professionals) participated in the study across a range of health and social care settings in the North West of England (2011–2014).\ud Results: A number of key domains were identified and prioritised by consensus for inclusion in the CAT. The 8 domains fit within two overarching themes of the reported carer experience; the support needed by the carer to provide care and the support needed for the carer’s own health and well-being. The resultant CAT is an evidence-based alert thermometer consisting of 10 questions, guidance on the possible actions for each alert and space for an action plan to be jointly agreed by the assessor and carer. Preliminary piloting of the CAT has shown it to be valued, fit for purpose and it can be administered by a range of personnel.\ud Conclusions: The CAT enables the identification of current and potential future needs so a proactive approach can be taken to supporting the carer as their role develops over time, with a view to enhancing their well-being and preventing avoidable hospital admissions; ultimately supporting patient choice to remain in their own home.

One in 10,000 children die of a life-threatening condition annually, and in the UK, nearly forty hospices exist to provide care for children with life-threatening illnesses. This study was designed to explore what is offered within children's hospices and how they cared for the growing number of older children and adolescents who are living with life-limiting illness.A questionnaire was sent to all of the children's hospices in the UK (n=40), as listed in the Hospice Information (2003) Hospice Information, Hospice Directory, 2003. A number of different areas were covered e.g. staffing, services offered, nature of care provided and, in relation to older children, their links with adult hospices.Thirty-three of the 40 children's hospices returned the questionnaires--an 83% response rate. Care of adolescents with life-threatening illness was identified as an issue with more than 50% of the hospices stating that they had difficulty in liaison with adult hospices to offer support for adolescents.This study highlights that there is consistency in the high level of care being provided to children up to the age of 18, but provision of care after this age is patchy and not always readily available.

Background The new General Medical Services contract in England means many GPs have transferred out-of hours work to their primary care organization, with implications for continuity of palliative care in community hospitals. Aim To examine existing arrangements for out-of-hours medical cover in community hospitals, focusing on palliative care. Methods Telephone survey of community hospital managers/senior nurses across England and Wales. Results Interviews (n=62) revealed nursing staff were satisfied with existing out-of-hours care. Concern was expressed about the future of out-of-hours medical care from GPs as new services will cover larger areas, meaning unknown doctors may attend, taking longer to arrive. Conclusion Arrangements for out-of-hours medical cover in community hospitals are in transition, threatening the continuity of care for dying patients.

End of life care or palliative care has been acknowledged as important over the last 30 years and it is essential that doctors have core training in palliative care during their undergraduate training. There is little knowledge of the nature of teaching of palliative care within the undergraduate curriculum. This review was undertaken to determine the evidence to create an effective and appropriate undergraduate curriculum in palliative care. All relevant databases were electronically searched from 1966 until 2001 and selected contemporary work included. Key authors were contacted and grey literature and conference abstracts were searched. Efforts were made to quality grade any evaluation studies of teaching, learning and assessment. Two hundred and eighty abstract citations were obtained--192 papers were excluded due to lack of relevance to this study. Eighty-eight abstracts were obtained and forty-nine papers included in the review. There were no randomized controlled trials of educational interventions or open effect studies. All studies included were descriptive and were graded as level of evidence C. The main findings include lack of consistency in what undergraduates are taught about palliative care. Teaching tends to be fragmented, ad hoc and lacks co-ordination. There are difficulties in recruiting appropriate teachers. Palliative care is rarely formally assessed. Teaching focused more on the acquisition of knowledge and skills rather than attitudes. It is suggested that guidelines should be established within each medical school to develop an integrated curriculum for palliative care with due reference to the multidisciplinary nature of palliative care.

Spiritual care is an integral part of palliative care and if asked, most members of a palliative care team would state they address spiritual issues. The majority of hospices have support from a chaplain. This study was to determine the roles of chaplains within hospices and to look at their levels of stress. A questionnaire containing both open and closed questions was sent to chaplains working within hospices in the UK. The questionnaire enquired about number of sessions, specific roles of chaplain, whether they were members of the multidisciplinary team and their sources of internal support. Stress was measured on a 10-point Likert scale and the GHQ12. One hundred and fifteen questionnaires were returned, with a 72% response rate. The majority (62%) defined their denomination as Church of England and Free Church (24%); 71% of respondents had parish commitments in addition to their hospice role. Roles were predominantly defined as spiritual care of patients and staff (95%) and bereavement support of relatives (76%) and 75% regularly attended the multidisciplinary meetings. Senior medical and nursing staff and other chaplains were perceived as providing most support. Median Likert score for stressfulness was 5, and 23% scored at or above the threshold on the GHQ12 for identifiable psychological morbidity. Clear role definition was associated with less perceived stress whereas the provision of bereavement support was associated with statistically significant increased perceived stress. The role of a chaplain within a hospice is varied and this study suggests that the provision of training and formal support is to be recommended.

Depression is a significant symptom for approximately 25% of palliative care patients, but is frequently unrecognized and untreated. This study was carried out to determine how senior doctors working in palliative medicine in the UK assessed and managed depression in their patients. A questionnaire was sent to all palliative care units with a designated consultant or medical director. Questions were asked about assessment and management of depression (pharmacological and nonpharmacological); difficulties encountered, qualifications and current post. The response rate was 63%; two-thirds (90) of respondents were consultants and a further 21 medical directors. The majority (73%) routinely assessed for depression with 27% using the Hospital Anxiety and Depression (HAD) Scale and 10% asking the patient 'are you depressed'? The most frequently prescribed medication was SSRI (80%). Less than 6% prescribed psychostimulants. Respondents reported difficulties with the assessment and management of depression which mainly focused on distinguishing symptoms of depression from sadness and whether it was appropriate to treat patients when life expectancy was short. Difficulties were identified in accessing psychiatric input by 47%. Depression is identified as being a difficult symptom to manage by many senior palliative care physicians in the UK and suggestions are made as to how some of theses issues can be addressed.

Psychiatric disorders are more prevalent in patients with cancer than in the general population.1,2 About 30% of such patients will be experiencing an 'adjustment reaction' and 20% will qualify for a formal psychiatric diagnosis, most commonly depression.3 For a quarter of all patients admitted to a palliative care unit, depression will be a significant symptom.4 Even in the general population the prevalence of depression is 6-10%, and those with a preexisting psychiatric disorder will be at special risk.5 More than 40 years have passed since Hinton drew attention to the issue of mental distress in the dying6 yet surveys still point to much unrecognized suffering;7 as much as 80% of the psychological and psychiatric morbidity of patients with cancer goes unrecognized and untreated. One reason is that many patients choose not to disclose their symptoms—perhaps because they feel it is a waste of the professional's time or because they think they are in some way blameworthy.8 But another factor may be that medical and nursing staff lack confidence in diagnosing depression in these circumstances.9 In this article I review the methods that can help in detection of depression and the options for intervention when it is identified.

Students entering medical school today will encounter an ageing population and a higher incidence of patients with terminal and life threatening illness. This study was carried out to determine the attitudes of pre-clinical medical students towards the care of patients for whom a cure is not possible. All students were invited to complete a 23-item questionnaire prior to any teaching in palliative care. Of the 186 students who participated in the study, 151 (79%) completed the pre-teaching questionnaire (males=59; females 90; median age 20 years; range 19-27]. Attitudes towards chronically ill and dying patients were generally positive. When comparing age with attitudes it was found that increasing age was associated with a more positive view of caring for patients with chronic or terminal illness, a more positive view of listening to patients reminisce and a more positive view of patients dying at home. Caring for patients at the end of life can be one of the most rewarding aspects of being a doctor. This study suggests that the majority of medical students have a positive attitude towards patients with chronic and terminal illness-the trend for encouraging older students to enter medicine may be an influencing factor.

Depression is the most common psychiatric illness in patients with terminal cancer. Depression not only lowers the quality of life for the patients and their families, but patients who are depressed may also have physical symptoms that are difficult to palliate and that improve as their depression is appropriately treated. However, up to 80% of the psychological and psychiatric morbidity that develops in cancer patients goes unrecognized and untreated and patients are often reluctant to spontaneously discuss symptoms with medical and nursing staff. In the UK, palliative care clinical nurse specialists have a key role in the assessment of symptoms and advising on management in patients with advanced metastatic cancer. A qualitative study was carried out to determine how specialist palliative care nurses, working both in the community and within a hospital, perceive, assess and manage depression in their patients. Seventeen nurses were interviewed. Nurses found it difficult to discuss depression with their patients and tended to focus on physical symptoms. The lack of training in identifying psychological and psychiatric symptoms was a source of concern to nurses as was the difficulties they encountered in trying to persuade medical staff that patients required further assessment or antidepressant medication. Nurses also felt that psychiatric expertise was not utilized as fully as it could be. The findings of this study have implications for the training and support of nurse specialists in the psychological and psychiatric assessment and management of palliative care patients.

Depression occurs in approximately 25% of palliative care patients. It often is not recognized and is, therefore, not treated. This can lead to difficulties in the management of physical symptoms, such as pain, and also cause much distress to patients and their families. Many professionals working in palliative care are concerned that screening for depression may not be appropriate in a population of patients whose illness is changing rapidly. To explore the value of screening, all patients attending a palliative care day unit were invited to participate in a 12-week study in which they were requested to complete at weekly intervals a previously validated depression-screening tool for palliative care. Fifty patients participated. The scores of all patients who scored below the cut-off threshold at initial assessment showed a mean change of ±0.56 (range −6 to +7) on the screening tool. This observation suggests that patients' scores on a self-completed scale that has been validated for use in the palliative care population remained largely stable during the last few months of life. Screening palliative care patients for depression at referral or first assessment may be useful in assessing depression within the palliative care setting.

Depression is a frequent symptom in palliative care patients but is often not diagnosed. In the U.K., the majority of patients with advanced cancer are referred to a clinical nurse specialist (CNS) whose remit includes the assessment of psychological symptoms and depression. Clinical nurse specialists have a key role in the diagnosis and management of patients with depression and it is important that they have the skills to do so. A postal questionnaire of all U.K. hospital, hospice, and community palliative care clinical nurse specialist teams was carried out to determine how they assessed depression in their patients. The response rate was 40%. Seventy-nine percent of all clinical nurse specialists believed their skills were poor in this area, and 92% felt they required further training. These beliefs were substantiated by the difficulties nurses encountered in assessing depression and by their beliefs regarding antidepressant medication. Clinical nurse specialists have a pivotal role in improving the detection and management of depression in palliative care patients, and require further training in this area.

Background There is a lack of research into suffering and what it means to the individual patient with advanced cancer and its importance in end of life care. Aims To explore the concept of suffering and distress by eliciting what individual patients with advanced cancer perceived as suffering and how they utilised their own resources to manage suffering. Method A qualitative study design of focused narrative interviews analysed by thematic analysis was conducted with a heterogeneous sample of 49 palliative day care patients. Results For those patients who perceived they were suffering, this study revealed a wide spectrum of definitions which could be described within the following areas; the unavoidable and avoidable suffering, physical and emotional suffering, suffering as loss and finally transformation through suffering. Conclusions These findings provide important insight that broadens and enriches our understanding into the concept of suffering and how patients utilise their resources, which may have important implications for end of life care.

People with preexisting mental illness are known to have difficulty accessing healthcare services including palliative care and people with dementia have similar issues accessing palliative care.The review addressed the time period from January 2013 to March 2014. There were few articles addressing issues for palliative and supportive care for patients with preexisting mental health issues. The main factor that would improve care is interdisciplinary working between mental healthcare teams and palliative care teams. In contrast, there were many published articles on the palliative and supportive care needs for people with dementia. These articles included consensus statements, models of care; studies of why models of care, for example Advanced Care Planning were not being implemented; and carer reports of care in the last year of life.Urgent research is required as to how support for people with preexisting mental illness who require palliative care can be improved--excellent liaison between mental health and palliative care teams is essential. There is much research on palliative care needs for people with dementia but an apparent lack of innovative approaches to care including care of people within their family home.

Summary Objectives In clinical trials where participants are likely to be able to distinguish between true and sham interventions, informing participants that they may receive a sham intervention increases the likelihood of participants ‘breaking the blind' and invalidating trial findings. The present study explored participants' perceptions of the consent process in a sham controlled acupressure trial which did not explicitly indicate participants may receive a sham intervention. Design Nested qualitative study within a randomised sham controlled trial of acupressure wristbands for chemotherapy-related nausea. Convenience sample of 26 patients participated in semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. Transcripts analysed thematically using framework analysis. Setting Study conducted within three geographical sites in the UK: Manchester, Liverpool, and Plymouth. Results All participants indicated that they believed they were fully informed when providing written consent to participate in the trial. Participants' perceived it was acceptable to employ a sham intervention within the trial of acupressure wristbands without informing potential participants that they may receive a sham treatment. Despite the fact that participants were not informed that one of the treatment arms was a sham intervention the majority indicated they assumed one of the treatment arms would be placebo. Conclusions Many trials of acupuncture and acupressure do not inform participants they may receive a sham intervention. The current study indicates patients' perceive this approach to the consent process as acceptable. However, the fact participants assume one treatment may be placebo threatens the methodological basis for utilising this approach to the consent process.

Depression is a significant symptom for 25% of patients admitted to a palliative care unit, but many of these symptoms are not identified and therefore not treated. Reasons for failure to diagnose depression are misconceptions regarding low mood as being a normal part of a terminal illness and also the patients' reluctance to disclose their thoughts and feelings. Medical and nursing staff working within palliative care may also find difficulty in distinguishing between what could be called appropriate sadness and a treatable depressive illness. In an effort to improve the detection of depression, many professionals are using rating scales or tools in order to improve the diagnosis and treatment. This review discusses the complex issues of diagnosis of depression and highlights why certain tools may not be so useful or applicable in the palliative care population.

It is estimated that for a quarter of all patients with advanced metastatic cancer, depression will be significant symptom. However up to 80% of the psychological and psychiatric morbidity which develops in cancer patients goes unrecognised and untreated. One of the main difficulties in establishing a diagnosis of an illness where there are no biological markers, physical signs, or diagnostics tests is deciding what can be called "appropriate sadness" as patients approach the end of life and what is a depressive illness. Criteria for diagnosing depression are discussed together with reasons why established screening tools used in other populations may not be appropriate to screen for depression in terminally ill patients. The use of antidepressants and the role of cognitive therapies are also discussed. For effective treatment of a depressive illness, treatment with antidepressant medication needs to be initiated sooner rather than later and patients may need close supervision to ensure compliance. The awareness of depression, the identification of symptoms, and the initiation of treatment is essential if patients are to be offered optimum palliation of psychological as well as physical symptoms.

It is widely recognised that depression is not detected and therefore not treated in patients who are terminally ill. It is difficult to distinguish depression from sadness at the end of life and many of the criteria for diagnosing depression are not appropriate in the terminally ill patient. There has been considerable interest in using screening tools at the time of referral or admission to a hospice, but to date none of these have been validated for use in palliative care patients. This pilot study of 25 patients admitted to a hospice found that a 100-mm linear visual analogue scale (VAS) correlated well with both the depression sub scale and total score of the Hospital Anxiety and Depression Scale (HADS) and was found to be quick and easy to complete by most patients. The finding suggest that the VAS may be useful as a screening tool for depression in patients with advanced metastatic disease and that larger studies comparing VAS to clinical psychiatric interviews should be undertaken.

CONTEXT: Both positive and negative results have been reported in the literature from the use of acupressure at the P6 point, providing evidence of highly suggestive but not conclusive results.OBJECTIVES: To clarify whether acupressure is effective in the management of chemotherapy-related nausea and vomiting.METHODS: A randomized, three-group, sham-controlled trial was designed. Patients with cancer receiving chemotherapy were randomized to receive standardized antiemetics and acupressure wristbands, sham acupressure wristbands, or antiemetics alone. Primary outcome assessment (nausea) was carried out daily for seven days per chemotherapy cycle over four cycles. Secondary outcomes included vomiting, psychological distress, and quality of life.RESULTS: Five hundred patients were randomized. Primary outcome analysis (nausea in Cycle 1) revealed no statistically significant differences between the three groups, although nausea levels in the proportion of patients using wristbands (both real and sham) were somewhat lower than those in the proportion of patients using antiemetics-only group. Adjusting for gender, age, and emetic risk of chemotherapy, the odds ratio of lower nausea experience was 1.18 and 1.42 for the acupressure and sham acupressure groups, respectively. A gender interaction effect was evident (P = 0.002). No significant differences were detected in relation to vomiting, anxiety, and quality-of-life measures.CONCLUSION: No clear recommendations can be made about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting as results did not reach statistical significance. However, the study provided evidence of encouraging signals in relation to improved nausea experience and warrants further consideration in both practice and further clinical trials.TRIAL REGISTRATION: This trial is registered with the ISRCT register, number ISRCTN87604299.

Objectives A lack of compassion in UK healthcare settings has received much recent attention. This study explores the experiences of people with dementia in the last year of life and time surrounding death and how the presence and lack of compassion, kindness and humanity influenced the experience of care. Design Qualitative in-depth interviews with bereaved informal carers of people with dementia. Setting United Kingdom. Participants Forty bereaved carers – 31 women and nine men – with an age range of 18–86 years and from wide socioeconomic backgrounds participated. Main outcome measures Experiences of carers of care for person with dementia during last year of life. Results The interviews highlighted differences and challenges in care settings in providing compassionate, humanistic care and the impact of the care experienced by the person with dementia during the last year of life on informal carers during the bereavement period and beyond. Excellent examples of compassionate care were experienced alongside very poor and inhumane practices. Conclusion The concepts of compassion, kindness and humanity in dementia care are discussed within the paper. The ability to deliver care that is compassionate, kind and humanistic exists along a continuum across care settings – examples of excellent care sit alongside examples of very poor care and the reasons for this are explored together with discussion as to how health and social care staff can be trained and supported to deliver compassionate care.

Background Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective. Methods We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial. Results We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery. Conclusions This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs. Trial registration Current controlled trials ISRCTN68572159

Objective: Literature reviews suggest limited evidence of efficacy of antidepressant medication in patients with advanced cancer. This study was carried out to observe the longitudinal effect of antidepressant medication in a cohort of advanced cancer patients. Method: Patients were recruited from hospice day care settings and followed up longitudinally by series of measures for depression for 6 months or until death. Results: Six hundred and twenty nine patients recruited. One hundred and fifty six patients in total (25%) were receiving antidepressant medication for a median of 9.5 weeks (range 0–36 weeks) and a mean of 12.2 weeks. There was no significant difference in scores on depression measures over time for patients receiving antidepressant medication. Conclusions: Antidepressant medication for advanced cancer patients appeared to have little impact on depression scores. We postulate the holistic approaches within hospice day care may in themselves be interventions for depression thereby masking effect of pharmacological treatment. Further research should explore multi-intervention models for management of depression in advanced cancer.