Abstract
Effective palliative care requires a comprehensive assessment of symptoms to improve quality of life. This study evaluated the clinical utility of the Polish version of the Integrated Palliative Care Outcome Scale (IPOS-POL) in an inpatient setting. One hundred patients (68 oncological, 32 non-oncological) completed IPOS-POL at admission (T1) and after seven days (T2) between July 2022 and February 2023. While total IPOS scores remained stable (p = 0.3603), psychosocial distress increased significantly (p = 0.0217). Staff tended to underestimate drowsiness and psychosocial distress compared with patient self-reports. Female patients reported higher distress (p = 0.0374), and bedridden patients experienced more pain (p = 0.0146). Oncological patients reported greater pain (p = 0.0189), whereas non-oncological patients more frequently experienced breathlessness (p = 0.0297). These findings emphasize discrepancies in symptom perception between patients and staff and underline the importance of tailored interventions based on gender and functional status. Enhanced psychosocial support should be a priority in inpatient palliative care.
Keywords: geriatric symptom management, integrated palliative care outcome scale (IPOS), Palliative care, patient-reported outcomes, quality of life, symptom burden
INTRODUCTION
The growing prevalence of chronic and life-limiting illnesses due to increased life expectancy and aging populations highlights the need for comprehensive palliative care.1 Patients in these settings often face a complex interplay of physical symptoms, psycho-social distress, and functional decline, necessitating structured symptom assessment and quality-of-life evaluation.2
Palliative care focuses on enhancing the quality of life for patients and their families by managing distressing symptoms and providing holistic support.3 Effective interventions rely on systematic assessment tools that capture both objective and subjective aspects of patient well-being.4 Among these, the Integrated Palliative Care Outcome Scale (IPOS) is a valuable instrument for evaluating symptom burden and psychosocial concerns from both patient and clinician perspectives.5 Validated in multiple languages, including Polish (IPOS-POL), it has proven reliability in patients with advanced cancer and chronic organ failure.6 The IPOS is rooted in a biopsychosocial-spiritual model, which aligns with holistic nursing theory and emphasizes multidimensional assessment of patient needs.
Despite its widespread use, further research is needed to assess the IPOS scale’s clinical utility in inpatient palliative care. Understanding changes in patient-reported and staff-assessed symptom scores over time can provide insights into disease progression, symptom management efficacy, and the overall impact of palliative interventions.7 Additionally, demographic and clinical factors, such as gender and functional status, may influence symptom burden and perceived quality of life, necessitating a tailored approach to palliative care.8
This study aimed to assess the condition and needs of patients in an inpatient palliative care unit using IPOS-POL, a tool validated for Polish-speaking populations and rarely studied in Central European inpatient settings. It evaluated overall symptom burden and quality of life at two-time points—shortly after admission (T1) and after seven days of inpatient care (T2). The study compared patient-reported and staff-assessed scores to identify discrepancies in symptom perception. It examined changes over time to assess the impact of palliative interventions on somatic and psychosocial symptoms. It also explored gender differences in symptom burden and the effect of mobility status on perceived well-being. By identifying significant patterns and correlations within the IPOS data, this study aimed to contribute to a better understanding of symptom trajectories in palliative care, ultimately supporting the development of more personalized and effective symptom management strategies.
METHODS
Study design
This prospective observational study was conducted from July 2022 to February 2023 at our Institution’s Department of Palliative Medicine. It was approved by our institution’s Bioethics Committee (approval no. KB 828/22). Before inclusion, written informed consent was obtained from all participants.
Eligibility criteria
Verbal consent and the capacity to communicate effectively were prerequisites. One hundred patients admitted to the inpatient palliative care unit were enrolled in the study. Eligibility criteria required that participants be 18 years or older, provide verbal informed consent, and have preserved cognitive function, allowing them to answer the questionnaire independently. Patients who experienced cognitive impairment, severe disease progression, or an inability to provide informed consent were excluded.
Patient diagnosis and disease characteristics
The study population included patients with both oncological and non-oncological conditions. Of the 100 enrolled patients, 68 had an oncological diagnosis, and 32 had non-oncological diseases. While the IPOS-POL tool was originally validated in patients with advanced cancer, in this study it was also applied to individuals with severe non-oncological diseases. This extension is exploratory in nature, based on the conceptual validity of the IPOS in capturing multidimensional palliative symptoms irrespective of diagnosis. Its application to non-oncological populations has also been preliminarily explored in other recent studies.9 Nevertheless, this methodological choice introduces a limitation that is addressed in the discussion.
Among the oncological group, the most frequent diagnoses included lung cancer (n = 15), breast cancer (n = 12), colorectal cancer (n = 11), pancreatic cancer (n = 9), prostate cancer (n = 7), gastric cancer (n = 6), and other malignancies (n = 8). The disease stages were classified as advanced/metastatic in 58 cases and locally advanced in 10 cases. Patients with active oncological treatment (chemotherapy, radiotherapy, targeted therapy) at the time of admission comprised 22% (n = 15), whereas 78% (n = 53) had transitioned to palliative or best supportive care.
The non-oncological group included patients with chronic obstructive pulmonary disease (COPD, n = 10), end-stage heart failure (n = 8), chronic kidney disease (n = 6), amyotrophic lateral sclerosis (ALS, n = 5), and advanced liver disease (n = 3). Disease severity in this group was assessed based on clinical deterioration, dependence on supportive care, and previous hospital admissions.
Study procedure and data collection
The study assessed patients using the IPOS-POL, a validated instrument designed to evaluate the symptom burden and psychosocial well-being of palliative care patients. The IPOS-POL questionnaire consists of 10 questions for patients and nine for health care staff. It includes one open-ended question concerning the patient’s most significant problem, one question assessing somatic symptoms scored from 0 (none) to 4 (severe), and seven questions addressing psychosocial well-being, also scored from 0 (never) to 4 (always). The total IPOS score ranges from 0 to 76, with higher scores indicating a more significant symptom burden and a worse overall condition.
Each patient was assessed at two-time points. The first assessment (T1) was conducted a few days after admission, with responses based on the previous three days of the patient’s stay. The second assessment (T2) was performed seven days after admission. Patients had the option to complete the questionnaire independently, with assistance from a family member, caregiver, or close friend, or with the help of medical staff if necessary. The study also collected additional patient data, including age, gender, primary diagnosis, disease stage, ongoing treatments, place of residence (urban or rural), and functional status (ambulatory or bedridden).
The primary objective was to evaluate the overall symptom burden and quality of life at T1 and T2, assessing whether symptoms improved, remained stable, or worsened over time. The study also aimed to compare patient-reported and staff-assessed symptom scores, identifying discrepancies in symptom perception. Additionally, it investigated whether gender differences influenced symptom burden and quality of life. It examined the impact of functional status, distinguishing between ambulatory and bedridden patients, to determine whether mobility status affected symptom severity or psychosocial distress. Further subgroup analyses were conducted to explore whether symptom burden varied based on diagnosis type (oncological vs. non-oncological) and disease stage.
Missing data were excluded listwise and the administration process for IPOS-POL was clarified.
Sample size calculation
Sample size was calculated to detect a clinically meaningful change in total IPOS scores between the two assessment points (T1 and T2), using a two-tailed paired Wilcoxon signed-rank test. The expected mean difference of three points and standard deviation of 6 were based on estimates from previous studies in inpatient palliative care populations.9 With a significance level (alpha) of 0.05 and a power of 80%, the minimum required sample size was calculated to be 86 participants. To account for potential attrition, the final planned sample size was increased to 100 patients.
Statistical analysis
All statistical analyses were conducted using STATISTICA 13.0 (StatSoft). Descriptive statistics were applied, with continuous variables presented as means, standard deviations, medians, and ranges, while categorical variables were expressed as frequencies and percentages. The Shapiro-Wilk test was used to evaluate the normality of data distribution. Comparisons between two independent groups were performed using the Mann-Whitney U test, while the Kruskal-Wallis test was applied for comparisons across more than two groups. Changes in IPOS scores over time (T1 vs. T2) were analyzed using the Wilcoxon signed-rank test for paired non-parametric data. The correlation between patient-reported and staff-assessed symptom scores was examined using Spearman’s rank correlation coefficient. Comparisons between the two time points were made using the Wilcoxon signed-rank test. Missing data were excluded using listwise deletion. Correction for multiple comparisons was not applied, as this was an exploratory, hypothesis-generating study. However, the results should be interpreted with caution due to the increased risk of Type I error. Effect sizes (Cohen’s d) have been calculated and presented for statistically significant comparisons to assess the magnitude of the differences. Subgroup analyses based on gender, diagnosis (oncological vs. non-oncological), and functional status (ambulatory vs. bedridden) were pre-specified in the study protocol. A p-value of <0.05 was considered statistically significant for all analyses.
RESULTS
Summary of participation and retention
The study assessed 122 patients for eligibility, as seen in Figure 1. Of these, 22 patients were excluded, 15 did not meet the inclusion criteria, and seven declined participation. As a result, 100 patients were enrolled in the study and included in the first assessment (T1).
FIGURE 1.
STROBE flow diagram.
During the follow-up period, fifteen patients were lost for various reasons: five patients died, four were discharged home, and five experienced cognitive decline that prevented continued participation. Additionally, one patient discontinued participation due to personal reasons.
By the time of the second assessment (T2), 85 patients remained in the study and were analyzed. The final analysis was conducted on these 85 participants, ensuring that the collected data reflected the symptom burden and quality-of-life changes over the inpatient palliative care period.
A comparative analysis of baseline characteristics was performed between participants who completed both assessments (n = 85) and those who were lost to follow-up (n = 15). Variables including age, gender, primary diagnosis (oncological vs. non-oncological), and functional status (ambulatory vs. bedridden) at baseline were examined. No statistically significant differences were found between these groups (Supplementary Digital Content Table 1, available at: http://links.lww.com/HNP/A30), suggesting that attrition was unlikely to introduce systematic bias into the results.
Baseline characteristics
The baseline characteristics of the patients, including age, gender distribution, disease diagnosis and stage, and functional status (ambulatory vs. bedridden) at both T1 and T2, are displayed in Table 1. The mean age of the participants was 72.7 ± 11.1 years, with women comprising 43.4% of the initial cohort.
TABLE 1.
Baseline Characteristics of Study Population
| Characteristic | T1 (N = 100) | T2 (N = 85) |
|---|---|---|
| Mean Age (years) | 72.7 | 72.5 |
| Female Patients (%) | 43.0% | 40.0% |
| Male Patients (%) | 57.0% | 60.0% |
| Ambulatory Patients (%) | 52.0% | 48.0% |
| Bedridden Patients (%) | 48.0% | 52.0% |
| Oncological Diagnosis (%) | 68.0% | 65.0% |
| Non-Oncological Diagnosis (%) | 32.0% | 35.0% |
Functional status analysis—IPOS score
The IPOS-POL scores, assessed at T1 and T2, were compared for patient-reported and staff-assessed symptoms. Table 2 summarizes the overall scores, somatic symptoms, and psycho-social distress. The overall score showed no significant difference between T1 and T2 (p = 0.3603), but a statistically significant increase in patient-reported psycho-social distress was observed (p = 0.0217 for patient-reported scores).
Table 2.
IPOS Scores—Overall and by Patient Groups
| (a) IPOS Scores for All Patients | |||||
|---|---|---|---|---|---|
| Assessment | T1 Patient | T1 Staff | T2 Patient | T2 Staff | p-value |
| Overall Score | 19.3 ± 8.7 | 15.9 ± 8.4 | 19.9 ± 7.8 | 16.2 ± 7.6 | 0.3603 |
| Somatic Symptoms | 9.3 ± 6.4 | 8.5 ± 6.0 | 8.6 ± 5.9 | 8.3 ± 5.5 | 0.4027 |
| Psycho-social Distress | 10.0 ± 3.5 | 7.2 ± 4.1 | 11.0 ± 3.5 | 8.1 ± 3.6 | 0.0217 |
| (b) IPOS Scores by Gender | ||||
| Assessment | T1 Women | T1 Men | p-value | Effect size (Cohen’s d) |
| Drowsiness | 1.1 ± 1.2 | 0.7 ± 1.0 | 0.0522 | 0.36 (small) |
| Family Worry | 2.8 ± 1.6 | 2.3 ± 1.6 | 0.0374 | 0.31 (small) |
| Calmness | 0.5 ± 0.8 | 0.8 ± 1.0 | 0.0121 | 0.34 (small) |
| (c) IPOS Scores by Diagnosis and Disease Stage | ||||
| Diagnosis/Disease Stage | Mean Score (T1) | Mean Score (T2) | p-value | Effect size (Cohen’s d) |
| Oncological Diagnosis—Pain | 7.2 | 7.0 | 0.0189 | 0.27 (small) |
| Oncological Diagnosis—Fatigue | 6.5 | 6.2 | 0.0412 | 0.23 (small) |
| Oncological Diagnosis—Drowsiness | 5.9 | 5.7 | 0.0365 | 0.19 (negligible) |
| Non-Oncological Diagnosis—Breathlessness | 8.1 | 8.4 | 0.0297 | |
| Advanced Cancer—Fatigue | 7.8 | 7.5 | 0.0412 | |
| Advanced Cancer—Drowsiness | 6.3 | 6.1 | 0.0365 | |
Gender based IPOS score
Table 2 also presents IPOS scores stratified by gender. Female patients reported higher levels of drowsiness (p = 0.0522; d = 0.36) and family worry (p = 0.0374; d = 0.31) than males, both reflecting small effect sizes. Similarly, differences by diagnosis and functional status were accompanied by small-to-moderate effect sizes (Table 2 and Table 3).
TABLE 3.
IPOS Scores by Functional Status
| Assessment | T1 Ambulatory | T1 Bedridden | T2 Ambulatory | T2 Bedridden | p-value | Effect size (Cohen’s d) |
|---|---|---|---|---|---|---|
| Low Mobility | 1.8 ± 1.4 | 2.6 ± 1.3 | 1.7 ± 1.4 | 2.3 ± 1.2 | 0.0029 | 0.63 (medium) |
| Pain | 1.3 ± 1.3 | 0.7 ± 1.1 | 1.4 ± 1.3 | 0.8 ± 1.1 | 0.0146 | 0.50 (medium) |
| Vomiting | 0.2 ± 0.5 | 0.3 ± 0.7 | 0.2 ± 0.6 | 0.1 ± 0.4 | 0.0268 | 0.21 (small) |
| Constipation | 1.0 ± 1.3 | 0.5 ± 1.2 | 0.6 ± 1.2 | 0.3 ± 0.8 | 0.0589 | 0.28 (small) |
| Feeling Anxious | 1.6 ± 1.3 | 0.9 ± 1.1 | 1.8 ± 1.4 | 1.5 ± 1.2 | 0.0044 | 0.48 (small-medium) |
IPOS scores by diagnosis and disease stage
Subgroup analysis revealed that patients with oncological diagnoses reported higher pain scores (p = 0.0189), whereas those with non-oncological conditions experienced higher levels of breathlessness (p = 0.0297). Among patients with advanced cancer, higher levels of fatigue (p = 0.0412) and drowsiness (p = 0.0365) were observed compared to those with locally advanced disease (table 2).
IPOS scores by functional status
Patients were divided into ambulatory and bedridden groups, and their symptom burden was analyzed separately (Table 3). Bedridden patients had significantly higher scores for low mobility (p = 0.0029), pain (p = 0.0146), and vomiting (p = 0.0268). Ambulatory patients reported higher levels of anxiety (p = 0.0044).
LIMITATIONS
This study has several limitations. First, it was observational and conducted in a single inpatient unit, which may restrict the generalizability of findings to other palliative care settings, such as home-based or hospice care. Moreover, the absence of a control or comparison group limits the ability to draw causal inferences about the effect of inpatient palliative care on symptom trajectories. However, the study’s exploratory design was intended to generate clinically meaningful hypotheses and descriptive insights rather than establish cause-effect relationships. Another important limitation is the relatively short observation period of seven days. While this timeframe allows for capturing immediate changes in symptom burden following admission, it is insufficient to meaningfully assess the full trajectory of symptoms or the sustainability of observed improvements. Future studies with longer follow-up periods are necessary to evaluate how symptom intensity and psychosocial distress evolve over time in palliative care settings. Future research should also explore the impact of specific interventions on symptom relief and quality of life, considering factors such as pharmacological treatments, psychological therapies, and supportive care measures.
Although 15% of patients did not complete the second assessment due to death, discharge, or cognitive deterioration, comparative analysis revealed no significant differences in baseline characteristics between completers and non-completers. This helps mitigate concerns about attrition bias, although results should still be interpreted cautiously. Moreover, qualitative studies exploring patient and caregiver experiences could provide deeper insights into the underlying factors contributing to symptom burden and psychosocial distress. Understanding patient perspectives on symptom management and quality of life in palliative care settings may further refine assessment and intervention strategies.
DISCUSSION
This study assessed the condition and needs of patients in an inpatient palliative care unit using IPOS-POL. Analyzing patient-reported and staff-assessed symptoms at two time points aimed to evaluate the overall symptom burden, identify discrepancies in perception, and explore the impact of gender and functional status on symptom experience. These findings support the holistic nursing model, which prioritizes patient-centered assessments that encompass both somatic and psychosocial domains.
Key findings and interpretation
The results indicated that overall symptom burden, measured by the IPOS total score, remained stable over time. While somatic symptom scores did not significantly change between T1 and T2, there was a notable increase in psychosocial distress, particularly in patient-reported assessments. This finding underscores the importance of continuous psychological support in inpatient palliative care, as patients may experience heightened distress over time, potentially due to increased awareness of their condition or disease progression.10-12
Discrepancies between patient-reported and staff-assessed symptoms were observed, particularly in the domains of drowsiness and psychosocial distress. Staff assessments tended to underestimate symptoms compared to patient reports, a trend that aligns with previous studies on symptom perception in palliative care settings.13-15 These differences highlight the necessity of incorporating patient-reported outcomes into routine care, ensuring that the subjective symptom burden is adequately addressed.16
Gender differences were also evident in the analysis. Women reported higher drowsiness and more significant family concern, while staff-rated assessments indicated that women felt less calm than men. These findings suggest that female patients may experience more significant psychosocial distress, possibly due to variations in coping mechanisms, social roles, or emotional expression. Previous research has shown that gender influences the experience of pain and anguish in palliative care, reinforcing the need for gender-sensitive symptom management approaches.17-19
Mobility status was another critical factor affecting symptom burden. Bedridden patients exhibited significantly higher scores for low mobility, pain, and vomiting, whereas ambulatory patients reported more significant anxiety. These differences suggest that physical deterioration is associated with increased somatic distress, while relatively higher-functioning patients may experience more significant psychological concerns.20 Tailoring interventions to address both mobility-related symptoms and psychological distress is crucial for optimizing palliative care outcomes.18,21
The results of this study demonstrate that symptom burden varies significantly based on diagnosis and disease stage. Patients with oncological conditions experienced substantially higher pain scores compared to those with non-oncological diseases, which is consistent with findings from previous palliative care research.22 Additionally, fatigue and drowsiness were more pronounced in patients with advanced cancer, likely due to disease progression and the effects of prior oncological treatments.23 In contrast, patients with non-oncological conditions, particularly those with COPD and end-stage heart failure, reported higher levels of breathlessness, which aligns with the known symptomatology of these diseases.24
These findings emphasize the need for diagnosis-specific symptom management strategies in palliative care settings, ensuring targeted interventions for pain relief in cancer patients and improved respiratory support for individuals with chronic pulmonary and cardiovascular diseases.25 A significant methodological consideration is the inclusion of patients with non-oncological diseases, such as advanced COPD, heart failure, or ALS. However, the IPOS-POL has been explicitly validated in populations with advanced cancer. While the scale’s multidimensional construct supports its use in broader palliative contexts, the lack of formal validation in non-oncological groups may impact the interpretability and psychometric robustness of results for this subgroup. Therefore, conclusions drawn from this portion of the sample should be interpreted with caution, and future studies should aim to validate the IPOS-POL specifically in non-oncological palliative populations. Understanding these distinctions can enhance patient-centered care, improving symptom control and overall quality of life. Given the observational nature of this study and the lack of a control group, our findings should be interpreted as exploratory and descriptive rather than causal. Nonetheless, the documented changes in symptom profiles offer valuable insights that may inform future interventional studies in similar populations. It is also important to note that the short, seven-day observation period limits our ability to conclude the long-term effectiveness of palliative care interventions or the natural course of symptom progression, particularly in patients with advanced and fluctuating disease trajectories.
This study is among the first in Central Europe to apply the IPOS-POL tool prospectively in an inpatient palliative care setting. Its use enabled the interdisciplinary team to quickly identify evolving symptom clusters, monitor treatment response, and engage in shared decision-making with patients and families. These results reinforce the utility of IPOS-POL in routine outcome monitoring and individualized care planning.
CONCLUSION
This study demonstrates the clinical feasibility and value of the IPOS-POL scale for holistic assessment and monitoring of patients in inpatient palliative care settings in Poland. The findings underscore the importance of addressing psychosocial distress alongside somatic symptoms, tailoring interventions based on gender and functional status, and integrating patient-centered approaches into palliative care practice. Future research should focus on long-term symptom trajectories, intervention effectiveness, and qualitative patient experiences to enhance care strategies for individuals with life-limiting illnesses.
IMPLICATIONS
For nursing practice, the use of IPOS-POL provides a practical and validated tool for early symptom detection, intervention prioritization, and collaborative care planning. Nurses can use this scale not only to quantify symptom burden but also to initiate communication with patients and families, particularly regarding unresolved concerns or emerging psychological distress.
The findings emphasize the importance of using comprehensive assessment tools like IPOS to capture both physical and psychosocial aspects of palliative care.19 Given the discrepancies between patient-reported and staff-assessed symptoms, integrating patient perspectives into treatment planning is essential to ensure holistic, personalized care.26
Furthermore, the increase in psychosocial distress over time highlights the need for continuous psychological support, particularly for patients experiencing heightened anxiety and family-related concerns.27 Multidisciplinary interventions, including psychological counseling, family support programs, and targeted symptom management strategies, should be considered to address these evolving needs.9
The observed gender differences and functional status variations suggest that a one-size-fits-all approach to symptom management may be insufficient.28 Instead, personalized strategies that consider gender-specific and mobility-related symptom profiles may enhance the effectiveness of palliative care interventions.29
Footnotes
No additional contributors outside of the listed authors participated in the study. No external writing assistance was used in the preparation of this manuscript.
The authors have no sources of funding to declare for this manuscript.
The authors declare that no financial or personal relationships with other individuals or organizations could inappropriately influence (bias) this work. No author has received employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, research grants, or other funding related to this study.
No study sponsors were involved in the design, data collection, analysis, interpretation, writing, or decision to submit the manuscript for publication.
This study was conducted in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and the Declaration of Helsinki (1975, revised in 2000).
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.hnpjournal.com).
Contributor Information
Monika Grochowicka, Email: monikagrochowicka@gmail.com.
Wojciech Leppert, Email: wojciechleppert@wp.pl.
Małgorzata Reysner, Email: mreysner@ump.edu.pl.
Sylwia Kropińska, Email: skropins@ump.edu.pl.
Maciej Sopata, Email: msopata@ump.edu.pl.
Tomasz Reysner, Email: treysner@ump.edu.pl.
Grzegorz Kowalski, Email: gkowalski@ump.edu.pl.
Katarzyna Wieczorowska–Tobis, Email: kwt@tobis.pl.
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