Emotionally reflexive labour in end-of-life communication

Within palliative care, clear and open communication about death is encouraged. Euphemisms are discouraged as threats to promoting clear understanding of the prognosis; to opening communication about what a good death means to individual patients and families; and to fostering collaborative planning aimed at achieving this 'good death'. Principles of patient-centred and culturally competent care, however, which reflect trends of individualisation, plurality and multiculturalism that are characteristic of late modernity, encourage respect for and support of patients' and families' preferences. These may include wishes to avoid open communication, preferences for euphemisms, and definitions of a 'good death' that vary from the practitioner's, and within families. The aim of this study was to examine how physicians navigate these competing priorities. Analysis is based on interviews with 23 doctors, ranging in experience from medical students through to senior palliative care specialists, and eight recorded observations of palliative care multidisciplinary team meetings with 52 clinicians collected in 2017 at two hospitals in one Australian metropolitan area. Findings show that synonyms familiar to clinicians are often used to communicate prognoses in multidisciplinary meetings. In communication with patients and families, doctors rely on emotional and cultural cues to decipher the preferred terminology and response. Drawing on a late modern re-imagination of emotion management, we conceptualise the work performed in this context as emotionally reflexive labour. These findings suggest that blanket protocols for direct communication overlook the complexity of end-of-life communication in an era where a 'good death' is understood to be culturally relative.

Heideggerian hermeneutic phenomenology as method: modelling analysis through a meta-synthesis of articles on Being-towards-death

While the richness of Heideggerian philosophy is attractive as a healthcare research framework, its density means authors rarely utilise its fullest possibilities as an hermeneutic analytic structure. This article aims to clarify Heideggerian hermeneutic analysis by taking one discrete element of Heideggerian philosophy (Being-towards-death), and using it's clearly defined structure to conduct a meta-synthesis of Heideggerian phenomenological studies on the experience of living with a potentially life-limiting illness. The findings richly illustrate Heidegger's philosophy that there is either an inauthentic positioning towards death, or an authentic positioning towards death with a proposition that (1) death is certain; (2) death is indefinite; (3) death is non-relational; and (4) death is not-to-be-outstripped. None of the 29 included studies on the experience of a confrontation with death fully utilised this framework, despite claiming a grounding in Heideggerian thought. This demonstrates the value in modelling how Heideggerian existential structures can be used proactively as analytical 'hooks' for data in research claiming a basis in this philosophy and/or method. By modelling the potential application of an important Heideggerian philosophical construct to published qualitative data, this meta-synthesis has revealed new domains and more nuanced understandings of the temporal structure of Being-towards-death. Such an approach helps to more fully unveil the existential concerns of people at the core of interpretative phenomenological enquiry and may provide a blueprint to map either primary or synthesised data to other key ontological existentials.

Pros and Cons of Physician Aid in Dying

The question of a physician's involvement in aid in dying (or "assisted suicide") is being debated across the country. This article adopts no one position because its authors hold contrasting views. It aims instead to articulate the strongest arguments in favor of aid in dying and the strongest arguments opposed. It also addresses relevant terminology and reviews the history of its legalization in the United States.

Identifying neuronal correlates of dying and resuscitation in a model of reversible brain anoxia

We developed a new rodent model of reversible brain anoxia and performed continuous electrocorticographic (ECoG) and intracellular recordings of neocortical neurons to identify in real-time the cellular and network dynamics that successively emerge throughout the dying-to-recovery process. Along with a global decrease in ECoG amplitude, deprivation of oxygen supply resulted in an early surge of beta-gamma activities, accompanied by rhythmic membrane depolarizations and regular firing in pyramidal neurons. ECoG and intracellular signals were then dominated by low-frequency activities which progressively declined towards isoelectric levels. Cortical neurons during the isoelectric state underwent a massive membrane potential depolarizing shift, captured in the ECoG as a large amplitude triphasic wave known as the "wave-of-death" (WoD). This neuronal anoxic depolarization, associated with a block of action potentials and a loss of cell integrative properties, could however be reversed if brain re-oxygenation was rapidly restored (within 2-3.5 min). The subsequent slow repolarization of neocortical neurons resulted in a second identifiable ECoG wave we termed "wave-of-resuscitation" since it inaugurated the progressive regaining of pre-anoxic synaptic and firing activities. These results demonstrate that the WoD is not a biomarker of an irremediable death and unveil the cellular correlates of a novel ECoG wave that may be predictive of a successful recovery. The identification of real-time biomarkers of onset and termination of cell anoxic insult could benefit research on interventional strategies to optimize resuscitation procedures.

The emotional labour of quality improvement work in end of life care: a qualitative study of Patient and Family Centred Care (PFCC) in England

BACKGROUND

There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements.

METHODS

The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme.

RESULTS

One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of 'emotional labour' that staff members need to invest in implementing the programme.

CONCLUSIONS

Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The 'emotional labour' for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement.

Palliative Care for Dementia: 2020 Update

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.

Dying in acute hospitals: voices of bereaved relatives

Background

Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals.

Methods

Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate).

Results

The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support.

Conclusions

This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative’s priorities for EoLC in acute hospitals and can advance care providers’, policy makers’ and educationalists’ priorities for service improvement.

Economics of death and dying: a critical evaluation of environmental damages and healthcare reforms across the globe

The economics of death and dying highlighted that environmental factors negatively influence healthcare sustainability. Therefore, this study conducted a system-based literature review to identify the negative externality of environmental damages on global healthcare reforms. Based on 42 peer-reviewed papers in the field of healthcare reforms and 12 papers in the field of environmental hazards, we identified 25 factors associated with death and dying and 15 factors associated with health-related damages across the world respectively. We noted that environmental factors are largely responsible to affect healthcare sustainability reforms by associating with the number of healthcare diseases pertaining to air pollutants. The study suggests healthcare practitioners and environmentalists to devise long-term sustainable healthcare policies by limiting highly toxic air pollutants through technology-embodied green healthcare infrastructure to attained efficient global healthcare recovery.

Nurses' perceptions and experiences of caring for patients who die in the emergency department setting

INTRODUCTION

The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected.

AIM

This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED.

METHODS

Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically.

RESULTS

211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected.

CONCLUSIONS

ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

Discussing end of life wishes - the impact of community interventions?

Background

Many people do not discuss end of life preferences with those closest to them, although this can be beneficial to the individual and wider population. This study evaluated a community intervention to promote end of life preparation and discussion among people who are currently well.

Methods

A series of presentations and workshops (the intervention) were delivered to community groups and people working within health and social care. Participants were invited to complete a three-stage follow-up survey at Baseline, Post intervention and at three months' follow-up.

Results

Baseline questionnaires were completed by 498 individuals. Overall, 51% reported talking with close family or friends about their end of life care and 58% reported talking about what they would like to happen after their death. There was a significant positive relationship between increasing age group and having talked about end of life wishes. The majority of participants were already comfortable in talking about end of life (overall mean score 8.28/10). Post intervention, 73% stated that they planned to take action including 61% who planned a specific conversation and 55% who planned another action. At follow-up 64% reported that they had taken some action due to the intervention, including 43% who had talked about their own end of life preferences and 39% who had taken some other action.

Conclusions

Well-designed community-based interventions can be successful in prompting people to consider and discuss their end of life preferences.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0407-8) contains supplementary material, which is available to authorized users.

End-of-Life Care and Bereavement Issues in Human Immunodeficiency Virus-AIDS

This review article addresses end-of-life care issues characterizing human immunodeficiency virus progression by delineating associated stages of medical and nursing care. The initial progression from primary medical and nursing care aimed at functional cure to palliative care is discussed. This transition is considered in accord with the major symptoms experienced, including fatigue, pain, insomnia; decreased libido, hypogonadism, memory, and concentration; depression; and distorted body image. From the stage of palliative care, progression is delineated onward through the stages of hospice care, death and dying, and the subsequent bereavement process.

Discussing death: Making end of life implicit or explicit in paediatric palliative care consultations

OBJECTIVE

To consider whether and how family members and clinicians discuss end of life during paediatric palliative care consultations.

METHODS

Nine naturally occurring paediatric palliative care consultations were video recorded and analysed using conversation analytic methods.

ANALYSIS

Focusing on three consultations in which end of life was treated as a certain outcome, analysis explored ways in which end of life was made either implicit or explicit within these consultations. Our analysis suggests that end of life was made explicit when: 1) ancillary to the current focus of discussion, 2) in relation to someone else's child, or 3) specifically relevant to the local context of the discussion. More commonly, in all other instances in the data, end of life was made implicit during discussions relating to this matter.

CONCLUSION

This preliminary research indicates that the local context of a conversation can influence how end of life is mentioned and discussed.

PRACTICE IMPLICATIONS

Clinicians often are encouraged to promote honest and 'open' discussions about end of life. Our findings show that it is not necessary to explicitly mention end of life in order to discuss it.

Development of a Hybrid Simulated Patient Experience to Practice Care of the Dying Older Adult

INTRODUCTION

Care of the dying older adult includes critical skills that emerging physicians should master but are not consistently taught. Simulation has been shown to be an excellent tool for teaching these skills in a standardized fashion. Simulation allows direct observation to assess and provide learner feedback. Our goal was to develop a learning activity to practice skills caring for the older adult at the end of life and identify areas in need of improvement.

METHODS

We developed a hybrid simulation in which fourth-year medical students and internal medicine (IM) residents cared for a 70-year-old patient (Laerdal SimMan 3G) who was actively dying in the emergency department. He was accompanied by his wife (standardized patient) and a nurse (standardized role). Over the academic year 2012-2013, we observed and videotaped 83 fourth-year medical students and 22 first-year IM residents in this setting. We assessed the learners' completion of 15 tasks associated with good end-of-life care.

RESULTS

All learners demonstrated professional activity working with the nurse, and all medical students but one gave opioids appropriately for pain. Only 19% of the medical students appropriately disclosed the patient's status to the wife using the words death and/or dying, and only 50% of the IM residents did so.

DISCUSSION

We successfully developed a learning activity in which learners can practice their skills caring for the dying older adult. We also determined that there is opportunity for improvement concerning communication, especially with the use of the words death and dying.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

Background

End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.

Methods

This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.

Results

Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.

Conclusions

Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

Pedagogy and the Art of Death: Reparative Readings of Death and Dying in Margaret Edson's Wit

Wit explores modes of reading representations of death and dying, both through the play's sustained engagement with Donne's Holy Sonnets and through Vivian's self-reflexive approach to her illness and death. I argue that the play dramatizes reparative readings, a term coined by Eve Kosofsky Sedgwick to describe an alternative to the paranoid reading practices that have come to dominate literary criticism. By analyzing the play's reparative readings of death and dying (as well as its representation of the shortcomings of paranoid readings), I show how Wit provides lessons about knowledge-making and reading practices in the field of health humanities.

IssuEs in Palliative care for people in advanced and terminal stages of Young-onset and Late-Onset dementia in GErmany (EPYLOGE): the study protocol

BACKGROUND

Scientific research on palliative care in dementia is still underdeveloped. In particular, there are no research studies at all on palliative care issues in young onset dementia (YOD), although significant differences compared to late onset dementia (LOD) are expected. Most studies have focused on persons with dementia in long term care (LTC) facilities but have neglected persons that are cared for at home. We hypothesize that unmet care needs exist in advanced and terminal stages of YOD and LOD and that they differ between YOD and LOD.

METHODS/DESIGN

The EPYLOGE-study (IssuEs in Palliative care for people in advanced and terminal stages of Young-onset and Late-Onset dementia in GErmany) aims to prospectively assess and survey 200 persons with YOD and LOD in advanced stages who are cared for in LTC facilities and at home. Furthermore, EPYLOGE aims to investigate the circumstances of death of 100 persons with YOD and LOD. This includes 1) describing symptoms and management, health care utilization, palliative care provision, quality of life and death, elements of advance care planning, family caregivers' needs and satisfaction; 2) comparing YOD and LOD regarding these factors; 3) developing expert-consensus recommendations derived from the study results for the improvement and implementation of strategies and interventions for palliative care provision; 4) and communicating the recommendations nationally and internationally in order to improve and adapt guidelines, to change current practice and to give a basis and perspectives for future research projects. The results will also be communicated to patients and their families in order to counsel and support them in their decision making processes and their dialogue with professional caregivers and physicians.

DISCUSSION

EPYLOGE is the first study in Germany that assesses palliative care and end-of-life issues in dementia. Furthermore, it is the first study internationally that focuses on the specific palliative care situation of persons with YOD and their families. EPYLOGE serves as a basis for the improvement of palliative care in dementia.

TRIAL REGISTRATION

The study is registered in ClinicalTrials.gov ( NCT03364179 ; Registered: 6. December 2017.

A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions

Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.

Early and late signs that precede dying among older persons in nursing homes: the multidisciplinary team's perspective

BACKGROUND

Nursing home residents in Sweden are old, frail and usually have multiple morbidities which often make dying a prolonged suffering. It has been found that older persons at nursing homes receive far less palliative care than younger persons, partly because it is difficult to identify when the final stage of life begins. The identification may help the staff to enable the older person and their families to participate in planning the care in accordance with their own preferences and values. With this in mind the aim was to explore the experiences of early and late signs preceding dying in older persons in nursing homes from the multidisciplinary team's perspective.

METHODS

The focus group method was used to interview 20 health-care professionals on the basis of semi-structured questions. Four focus groups were conducted at four nursing homes in two counties in southern Sweden. The groups included different professionals such as assistant nurses, registered nurses, occupational therapists, physiotherapists, social workers and unit managers. The analysis was conducted according to the focus group method developed by Kruger and Casey.

RESULTS

The analysis revealed one major theme, from unawareness to obviousness, which illustrates that the participants experienced dying as a happening, not a process, and found it difficult to identify early signs. Even though it was a new way of thinking, several suggestions of early signs were presented. The main category "Going into a bubble" illustrates early signs, which meant that the older person showed signs of wanting to withdraw from the outside world. The main category "The body begins to shut down" illustrates late signs, which meant that the older person showed signs that indicate that the body starts to prepare for death.

CONCLUSIONS

This study conveys new knowledge concerning the multidisciplinary team's collective experience of early and late signs that precede dying. This knowledge can increase the understanding of when a palliative care approach needs to be in place at nursing homes. The use of a palliative care approach in care planning requires consensus in the perception of the dying process of frail older persons.

A Contemporary Paradigm: Integrating Spirituality in Advance Care Planning

In the 25 years since advance care planning first drew the attention of the national healthcare and legal systems, gains in the rate of advance care directive completion have been negligible despite the effort of researchers, ethicists, and lawmakers. With the benefit of sophisticated healthcare technology, patients are living longer. Despite the benefits of increased longevity, it is widely acknowledged that enough has not been done to adequately address end-of-life care decisions at the crossroads between medical futility and quality of life. To arrive at a solution, researchers have focused on patient self-reflection, provider attitudes, health literacy, communication and the logistics of surrogacy, setting, payment, and documentation. However, a survey of the literature reveals one conspicuously absent theme. It is a phenomenon one would expect in the context of end-of-life discussion and decision making, that of spiritual inquiry. This article explores the history leading up and past approaches to advance care planning and then suggests the use of a theoretical model and a body of work concerning spiritual care as a new tack in the ongoing development of advance care planning.

Palliative Care for Dementia

With the growing care needs for the older population at the end of their lives, there has been a substantial increase in attention to the management of the patient with dementia in hospice and palliative care services. This article reviews issues in access to care and the optimal management of the patient with dementia, particularly in the context of neuropsychiatric complexities. Special issues such as delirium, cachexia, behavioral symptoms, and pain management are addressed. Future challenges in research such as the development of better prognostic models are noted as well as the importance of attention to access to care.

When a parent dies - a systematic review of the effects of support programs for parentally bereaved children and their caregivers

BACKGROUND

The death of a parent is a highly stressful life event for bereaved children. Several studies have shown an increased risk of mental ill-health and psychosocial problems among affected children. The aims of this study were to systematically review studies about effective support interventions for parentally bereaved children and to identify gaps in the research.

METHODS

The review's inclusion criteria were comparative studies with samples of parentally bereaved children. The focus of these studies were assessments of the effects on children of a bereavement support intervention. The intervention was directed towards children 0-18 years; but it could also target the children's remaining parent/caregiver. The study included an outcome measure that dealt with effects of the intervention on children. The following electronic databases were searched up to and including November 2015: PubMed, PsycINFO, Cinahl, PILOTS, ProQuest Sociology (Sociological Abstracts and Social Services Abstracts). The included studies were analysed and summarized based on the following categories: type of intervention, reference and grade of evidence, study population, evaluation design, measure, outcome variable and findings as effect size within and between groups.

RESULTS

One thousand, seven hundred and-six abstracts were examined. Following the selection process, 17 studies were included. The included studies consisted of 15 randomized controlled studies, while one study employed a quasi-experimental and one study a pre-post-test design. Thirteen studies provided strong evidence with regards to the quality of the studies due to the grade criteria; three studies provided fairly strong evidence and one study provided weaker evidence. The included studies were published between 1985 and 2015, with the majority published 2000 onwards. The studies were published within several disciplines such as psychology, social work, medicine and psychiatry, which illustrates that support for bereaved children is relevant for different professions. The interventions were based on various forms of support: group interventions for the children, family interventions, guidance for parents and camp activities for children. In fourteen studies, the interventions were directed at both children and their remaining parents. These studies revealed that when parents are supported, they can demonstrate an enhanced capacity to support their children. In three studies, the interventions were primarily directed at the bereaved children. The results showed positive between group effects both for children and caregivers in several areas, namely large effects for children's traumatic grief and parent's feelings of being supported; medium effects for parental warmth, positive parenting, parent's mental health, grief discussions in the family, and children's health. There were small effects on several outcomes, for example children's post-traumatic stress disorder (PTSD) symptoms, anxiety, depression, self-esteem and behaviour problems. There were studies that did not show effects on some measures, namely depression, present grief, and for the subgroup boys on anxiety, depression, internalizing and externalizing.

CONCLUSIONS

The results indicate that relatively brief interventions can prevent children from developing more severe problems after the loss of a parent, such as traumatic grief and mental health problems. Studies have shown positive effects for both children's and remaining caregiver's health. Further research is required including how best to support younger bereaved children. There is also a need for more empirically rigorous effect studies in this area.

Clinical decision making in the recognition of dying: a qualitative interview study

Background

Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: “What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?”

Methods

This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti.

Results

Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition.

Conclusions

This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers.

Feasibility and Acceptability of Implementing the Integrated Care Plan for the Dying in the Indian Setting: Survey of Perspectives of Indian Palliative Care Providers

INTRODUCTION

Capacity to provide end-of-life care in India is scored as 0.6/100, and very few people in India have access to palliative and end-of-life care. Lack of end-of-life care provision in India has led to a significant number of people receiving inappropriate medical treatment at the end of life, with no access to pain and symptom control and high treatment costs. The International Collaborative for the Best Care for the Dying Person is an initiative that offers the opportunity to apply international evidence on the key factors required to provide best care for the dying in the Indian context. The aim of this study is to ascertain the perceptions of Indian palliative care providers regarding the feasibility and acceptability of implementing the international program in the Indian setting.

METHODS

Thirty participants from 16 palliative care centers who had participated in the foundation course of the International Collaborative for Best Care for the Dying Person were purposively chosen for the study. All participants were asked to complete the survey questionnaire that had both open- and close-ended questions.

RESULTS

Twenty-three participants completed this survey. The majority of items in the international program were considered relevant, representative of end-of-life care and acceptable in Indian setting. However, participants felt that the concept of the multidisciplinary team (MDT) being responsible for recognizing death may not be possible in the existing Indian setting and a senior doctor may not always be available to document a MDT decision. Some participants felt that in the Indian setting, it was not always possible to communicate about the dying process and make patient aware of the same. A small number of participants felt that using leaflets for communicating end-of-life care process may not be always possible due to logistic reasons and cost. Six participants felt that giving the dying person the opportunity to discuss their wishes, feelings, faith, beliefs, and values may not be possible, representative, and not applicable in Indian setting. The majority of participants felt that using equipment such as a syringe driver for continuous infusion is relevant (n = 16) and representative (n = 13) of end-of-life care, however most thought that it could be challenging to apply in an Indian setting (n = 17), including concerns about lack of familiarity and knowledge and applicability in home care settings. Six participants had reservations regarding the limitation of life-sustaining treatment and felt that discussion and review of cardiopulmonary resuscitation should happen prior to patients entering their end-of-life phase. While most participants thought relevance, representation, and applicability of assessing skin integrity as important, a few participants felt this assessment challenging, especially in home setting, and recommended Braden scale to be used instead of Waterlow for assessing skin integrity. Most participants agreed on the importance of assisted hydration and nutrition; however, again a minority highlighted challenges in this area. Five participants felt that they would sometimes continue hydration under duress from a patient's family. Participants agreed unanimously on the relevance and representation of recording of physical symptoms by MDT-initial and ongoing-with a few participants indicating that frequent observations recommended in the care plan may not be feasible in home care setting. The majority also agreed on the relevance, representation (n = 21), and applicability (n = 18) of providing written information about after-death care, with a small number indicating challenges in the Indian setting, for example, very few unit currently having this information available (n = 2). Notifying general practitioners, primary care physicians, and other appropriate services on patients' death may not be easily applicable in the Indian setting.

CONCLUSIONS

The survey of palliative care providers about the feasibility and acceptability of integrated care plan at end of life has shown that the international program is relevant, representative of end-of-life care, and acceptable in Indian setting. As would be expected, a number of items need careful consideration and appropriate modification to ensure relevance, representation, and applicability to Indian sociocultural context. The results also suggest that palliative care providers need additional training for the implementation of some of the items in the development of an India-specific document and supporting quality improvement program.

Variations in Care Quality Outcomes of Dying People: Latent Class Analysis of an Adult National Register Population

CONTEXT

Symptom relief is a key goal of palliative care. There is a need to consider complexities in symptom relief patterns for groups of people to understand and evaluate symptom relief as an indicator of quality of care at end of life.

OBJECTIVES

The aims of this study were to distinguish classes of patients who have different symptom relief patterns during the last week of life and to identify predictors of these classes in an adult register population.

METHODS

In a cross-sectional retrospective design, data were used from 87,026 decedents with expected deaths registered in the Swedish Register of Palliative Care in 2011 and 2012. Study variables were structured into patient characteristics, and processes and outcomes of quality of care. A latent class analysis was used to identify symptom relief patterns. Multivariate multinomial regression analyses were used to identify predictors of class membership.

RESULTS

Five latent classes were generated: "relieved pain," "relieved pain and rattles," "relieved pain and anxiety," "partly relieved shortness of breath, rattles and anxiety," and "partly relieved pain, anxiety and confusion." Important predictors of class membership were age, sex, cause of death, and having someone present at death, individual prescriptions as needed (PRN) and expert consultations.

CONCLUSION

Interindividual variability and complexity in symptom relief patterns may inform quality of care and its evaluation for dying people across care settings.