Existential Loneliness in a Palliative Home Care Setting

Older persons' existential loneliness, as interpreted by their significant others - an interview study

BACKGROUND

In order to better understand people in demanding medical situations, an awareness of existential concerns is important. Studies performed over the last twenty years conclude that when dying and death come closer, as in the case with older people who are stricken by infirmity and diseases, existential concerns will come to the fore. However, studies concerning experiences of existential loneliness (EL) are sparse and, in addition, there is no clear definition of EL. EL is described as a complex phenomenon and referred to as a condition of life, an experience, and a process of inner growth. Listening to someone who knows the older person well, as significant others often do, may be one way of learning more about EL.

METHODS

This study is part of a larger research project on EL, the LONE study, where EL is explored through interviews with frail older people, their significant others and health care professionals. The aim of this study was to explore frail older (>75) persons' EL, as interpreted by their significant others. The study is qualitative and based on eighteen narrative interviews with nineteen significant others of older persons. The data was analysed using Hsieh and Shannon's conventional content analysis.

RESULTS

According to the interpretation of significant others, the older persons experience EL (1) when they are increasingly limited in body and space, (2) when they are in a process of disconnecting, and (3) when they are disconnected from the outside world.

CONCLUSION

The result can be understood as if the frail older person is in a process of letting go of life. This process involves the body, in that the older person is increasingly limited in his/her physical abilities. The older person's long-term relationships are gradually lost, and finally the process entails the older person's increasingly withdrawing into him- or herself and turning off the outside world. The result of this study is consistent with previous research that has shown that EL is a complex phenomenon, but the implications of this research include a deepened understanding of EL. In addition, the study highlights the interpretations of significant others.

Understanding and alleviating loneliness in later life: perspectives of older people

Purpose

There is extensive empirical literature that has sought to establish the prevalence of, and risk factors for, loneliness and social isolation in later life. Traditional empirical gerontological approaches have characterised loneliness as a linear experience that is both pathological and easily relieved with external intervention. The purpose of this paper is to explore the potential of qualitative interview data to reveal the possible complexities in understanding loneliness, including conceptual considerations for the dynamic and multi-dimensional aspects of loneliness.

Design/methodology/approach

The authors draw on two different studies where the purpose was to qualitatively examine the meaning of loneliness in the lives of older people and how they understood loneliness in the context of their daily life (n=37).

Findings

Interviews with “lonely” older people revealed that loneliness is a complex and dynamic experience. The authors also identified a range of internal and external factors that contribute to vulnerability for loneliness as well as resources to alleviate it.

Originality/value

The dynamic and multi-dimensional characteristics of loneliness in older people may help explain why community-based interventions to diminish it may be so challenging.

Evaluation of a Continuing Educational Intervention for Primary Health Care Professionals about Nutritional Care of Patients at Home

OBJECTIVE

Evaluate the effectiveness of a continuing educational intervention on primary health care professionals' familiarity with information important to nutritional care in a palliative phase, their collaboration with other caregivers, and their level of knowledge about important aspects of nutritional care.

DESIGN

Observational cohort study.

SETTING

10 primary health care centers in Stockholm County, Sweden.

PARTICIPANTS

140 district nurses/registered nurses and general practitioners/physicians working with home care.

INTERVENTION

87 professionals participated in the intervention group (IG) and 53 in the control group (CG). The intervention consisted of a web-based program offering factual knowledge; a practical exercise linking existing and new knowledge, abilities, and skills; and a case seminar facilitating reflection.

MEASUREMENTS

The intervention's effects were measured by a computer-based study-specific questionnaire before and after the intervention, which took approximately 1 month. The CG completed the questionnaire twice (1 month between response occasions). The intervention effects, odds ratios, were estimated by an ordinal logistic regression.

RESULTS

In the intra-group analyses, statistically significant changes occurred in the IG's responses to 28 of 32 items and the CG's responses to 4 of 32 items. In the inter-group analyses, statistically significant effects occurred in 20 of 32 statements: all 14 statements that assessed familiarity with important concepts and all 4 statements about collaboration with other caregivers but only 2 of the 14 statements concerning level of knowledge. The intervention effect varied between 2.5 and 12.0.

CONCLUSION

The intervention was effective in increasing familiarity with information important to nutritional care in a palliative phase and collaboration with other caregivers, both of which may create prerequisites for better nutritional care. However, the intervention needs to be revised to better increase the professionals' level of knowledge about important aspects of nutritional care.

INSPIRE (INvestigating Social and PractIcal suppoRts at the End of life): Pilot randomised trial of a community social and practical support intervention for adults with life-limiting illness

Background

For most people, home is the preferred place of care and death. Despite the development of specialist palliative care and primary care models of community based service delivery, people who are dying, and their families/carers, can experience isolation, feel excluded from social circles and distanced from their communities. Loneliness and social isolation can have a detrimental impact on both health and quality of life. Internationally, models of social and practical support at the end of life are gaining momentum as a result of the Compassionate Communities movement. These models have not yet been subjected to rigorous evaluation. The aims of the study described in this protocol are: (1) to evaluate the feasibility, acceptability and potential effectiveness of The Good Neighbour Partnership (GNP), a new volunteer-led model of social and practical care/support for community dwelling adults in Ireland who are living with advanced life-limiting illness; and (2) to pilot the method for a Phase III Randomised Controlled Trial (RCT).

Design

The INSPIRE study will be conducted within the Medical Research Council (MRC) Framework for the Evaluation of Complex Interventions (Phases 0–2) and includes an exploratory two-arm delayed intervention randomised controlled trial. Eighty patients and/or their carers will be randomly allocated to one of two groups: (I) Intervention: GNP in addition to standard care or (II) Control: Standard Care. Recipients of the GNP will be asked for their views on participating in both the study and the intervention. Quantitative and qualitative data will be gathered from both groups over eight weeks through face-to-face interviews which will be conducted before, during and after the intervention. The primary outcome is the effect of the intervention on social and practical need. Secondary outcomes are quality of life, loneliness, social support, social capital, unscheduled health service utilisation, caregiver burden, adverse impacts, and satisfaction with intervention. Volunteers engaged in the GNP will also be assessed in terms of their death anxiety, death self efficacy, self-reported knowledge and confidence with eleven skills considered necessary to be effective GNP volunteers.

Discussion

The INSPIRE study addresses an important knowledge gap, providing evidence on the efficacy, utility and acceptability of a unique model of social and practical support for people living at home, with advanced life-limiting illness. The findings will be important in informing the development (and evaluation) of similar service models and policy elsewhere both nationally and internationally.

Trial registration

ISRCTN18400594 18^th February 2015.

Patient Experiences of Loneliness: An Evolutionary Concept Analysis

Loneliness is a painful experience for patients. To clarity the concept of patient loneliness, this study undertook an evolutionary concept analysis based on a literature search in the main relevant databases. We identified 7 dimensions in adult patients' experiences of loneliness. These dimensions of loneliness have different causes and theoretical foundations, which have different implications for patient care. Patients may be lonely in their different relationships, including those with nurses and doctors. Loneliness in relation to health care professionals is a new application of the concept of loneliness that provides a useful starting point for future research.

Religion, Spirituality, or Existentiality in Bad News Interactions: The Perspectives and Practices of Physicians in India

A qualitative study was conducted to identify the role of religion, spirituality, or existentiality in clinical interactions. Grounded theory design was used to generate narrative data from 27 physicians working in four teaching hospitals in Karnataka, India, using a semi-structured interview schedule. Physicians reported that they explored religious, spiritual, and existential beliefs and practices of patients, along with other psychosocial and disease aspects, to assess their tolerance to bad news, to make decisions about delivering it, and to address the distress that might emerge from receiving bad news. They also reported taking recourse to religious or spiritual practices to cope with their own stress and feelings of failure.

'You only have one chance to get it right': A qualitative study of relatives' experiences of caring at home for a family member with terminal cancer

BACKGROUND

Relatives looking after a terminally ill family member at home face numerous challenges. Studies into relatives' experiences of home caregiving have been criticised for their descriptive nature and lack of theoretical underpinnings.

AIM

To explore the emotional challenges faced by home caregivers, and their experiences of healthcare professionals, from the perspective of existential psychology.

DESIGN

A qualitative study using semi-structured interviews. Transcripts were analysed thematically using the Framework approach.

SETTING/PARTICIPANTS

The study took place within an inner-city London hospice. Participants (n = 15) were recently bereaved adult relatives of cancer patients who cared for their family member at home.

RESULTS

Participants' experiences of being a caregiver and of professional support were highly varied. The analysis generated 15 themes which were organised into a framework based on Yalom's four 'existential conditions': responsibility (e.g. 'being the linchpin of care'; 'you only have one chance to get it right'), isolation (e.g. 'being on my own', 'being held in mind'), death (e.g. 'knowing but not knowing') and meaningfulness (e.g. 'giving something back', 'acceptance and gratitude'). Healthcare professionals were perceived as influential in both helping and hindering relatives in meeting the challenges they faced.

CONCLUSION

Existential psychology provides a theoretical perspective from which to understand the psychological complexity of the emotional challenges home caregivers face and a framework which may usefully inform research and clinical practice. Professionals' attentiveness to caregivers' needs can have powerful effects in assuaging anxiety, reducing isolation and enabling relatives to connect with the meaningfulness of caregiving.

Men's strategies for preserving emotional well-being in advanced prostate cancer: An interpretative phenomenological analysis

OBJECTIVE

This study explores men with advanced prostate cancers' own practices for promoting and maintaining emotional well-being using Interpretative Phenomenological Analysis.

DESIGN

Five men with advanced prostate cancer participated in face-to-face, semi-structured, in-depth interviews.

RESULTS

Within rich narratives of lost and regained well-being, two super-ordinate themes emerged--'living with an imminent and uncertain death' and 'holding on to life.' Well-being was threatened by reduced sense of the future, isolation and uncertainty. Yet, the men pursued well-being by managing their emotions, striving for the future whilst enjoying life in the present, taking care of their families and renegotiating purpose. Running through participant's accounts was a preference for taking action and problem-solving. Sense of purpose, social connectedness, and life engagement were revealed as concepts central to improving well-being, indicating areas which practitioners could explore with men to help them re-establish personal goals and life purpose.

CONCLUSIONS

The findings also add weight to the evidence base for the potential value of psychological interventions such as cognitive behaviour therapy and mindfulness in men with prostate cancer.

Older people living alone at home with terminal cancer

This study describes the lived experiences of older people coping with terminal cancer and living alone, focusing on how they face challenges of the biographical life changes from their disease progression. Face-to-face semi-structured interviews were conducted in two phases with palliative care clients of a community-based service in Western Australia (2009-2011): Brief interviews with 43 cancer patients who live alone and then in-depth interviews with 8 of them. Using biographical disruption as the analytical framework for interpreting the qualitative data, four main themes emerged: Biographical disruption: adjusting to change; Biographical continuity: preserving normality; Biographical reconstruction: redefining normality; and Biographical closure: facing the end. Biographical disruption was a suitable framework for analysis, permitting identification of the biographical disruptions of the individual's world and the reframing that is undertaken by the individual to maintain autonomy and independence while acknowledging and accepting their closeness to death. Understanding the factors associated with the individual's need to maintain their own identity will enable nurses working with this population to tailor support plans that meet the individuals' needs while maintaining or restoring the person's sense of self. Interventions that directly address end-of-life suffering and bolster sense of dignity and personhood need to be considered.

A qualitative exploration of the experiences of people living alone and receiving community-based palliative care

BACKGROUND

It is projected that in Australia there will be between 28% and 48% of palliative care patients living alone by the year 2031. As such, it will become increasingly important to provide appropriate home-based care in order to support these patients to be cared for and die at home.

AIM

This study explored the experiences of community-based palliative care cancer patients who live alone without a caregiver and what psychosocial issues they face.

METHODS

Face-to-face semistructured interviews were conducted with eight participants, and constant comparison was used for the analysis.

FINDINGS

Four main themes emerged: (1) loss of social networks; (2) maintaining independence; (3) balancing independence and the need for assistance; and (4) planning for the end of life.

DISCUSSION

Participants balanced independence with the need to accept help in order to maintain independence. Participants became more flexible about their preferred place of death.

CONCLUSION

The practice implications for working with people close to death who are living alone are that supports and assistance may be needed to maintain social networks and also a sense of independence.

Perioperative rehabilitation in operation for lung cancer (PROLUCA) - rationale and design

BACKGROUND

The purpose of the PROLUCA study is to investigate the efficacy of preoperative and early postoperative rehabilitation in a non-hospital setting in patients with operable lung cancer with special focus on exercise.

METHODS

Using a 2 x 2 factorial design with continuous effect endpoint (Maximal Oxygen Uptake (VO2peak)), 380 patients with non-small cell lung cancer (NSCLC) stage I-IIIa referred for surgical resection will be randomly assigned to one of four groups: (1) preoperative and early postoperative rehabilitation (starting two weeks after surgery); (2) preoperative and late postoperative rehabilitation (starting six weeks after surgery); (3) early postoperative rehabilitation alone; (4) today's standard care which is postoperative rehabilitation initiated six weeks after surgery. The preoperative rehabilitation program consists of an individually designed, 30-minute home-based exercise program performed daily. The postoperative rehabilitation program consists of a supervised group exercise program comprising cardiovascular and resistance training two-hour weekly for 12 weeks combined with individual counseling. The primary study endpoint is VO2peak and secondary endpoints include: Six-minute walk distance (6MWD), one-repetition-maximum (1RM), pulmonary function, patient-reported outcomes (PROs) on health-related quality of life (HRQoL), symptoms and side effects of the cancer disease and the treatment of the disease, anxiety, depression, wellbeing, lifestyle, hospitalization time, sick leave, work status, postoperative complications (up to 30 days after surgery) and survival. Endpoints will be assessed at baseline, the day before surgery, pre-intervention, post-intervention, six months after surgery and one year after surgery.

DISCUSSION

The results of the PROLUCA study may potentially contribute to the identification of the optimal perioperative rehabilitation for operable lung cancer patients focusing on exercise initiated immediately after diagnosis and rehabilitation shortly after surgery.

TRIAL REGISTRATION

NCT01893580.

The perspectives of bereaved family members on their experiences of support in palliative care

AIM

To explore family members' supportive interactions in palliative care and the emotional experiences that they associate with these interactions.

METHODS

Qualitative individual interviews were performed with bereaved family members recruited from an urban palliative care service in Sweden. The interviews were analysed using inductive qualitative content analysis.

RESULTS

Five categories of supportive interactions with staff members were linked with emotional consequences: informational support, supportive encounters, professional focus of staff, a supportive environment, and bereavement support. Having a dialogue with family members nurtured certainty and security, supportive encounters gave a warm and comforting feeling, and bereavement support contributed to feelings of strength. Environmental factors contributed to dignity.

CONCLUSION

Supportive interactions with staff and within a home-like environment help to build resilience if tailored to the family member's own needs.

Living in the presence of death: an integrative literature review of relatives' important existential concerns when caring for a severely ill family member

AIM

The aim of this study was to explore relatives' existential concerns when caring for a seriously ill family member as well as to describe interventions that meet these concerns.

METHODS

In this integrative literature review we assessed and classified 17 papers, 12 qualitative and 5 quantitative. Literature was sought in the databases Cinahl, PubMed, Psykinfo and Web of Science in September 2009 and in March 2010. Search terms used in different combinations were: family, family caregiver, next of kin, relatives, palliative, palliative care, end-of-life care, existential, spirit*. Data were redrawn from the papers results/findings, and synthesized into a new descriptive content.

RESULTS

The results were categorized from 13 papers exploring relatives' important existential concerns and 4 papers describing interventions aimed to support them in the existential area. A majority of the reviewed papers had been written in Sweden and concerned relatives of patients with cancer. One overarching theme, living in the presence of death, and three categories: responses to life close to death; support when death is near; and beyond the presence of death were created.

CONCLUSION

There is an urgent demand for large-scale studies using accurate methodology, as well as a need to design qualified investigations regarding the effects of various interventions, and to determine which interventions are the most effective in supporting relatives who experience existential distress manifested physically and/or psychologically. There is also a considerable demand for educational interventions among professionals in various healthcare settings to increase their knowledge regarding existential concerns among relatives.

To live close to a person with cancer--experiences of family caregivers

The purpose of this study was to obtain a deeper understanding of the experiences of Family Caregivers (FC) living close to a patient with cancer. This article reports on the findings from individual interviews with 15 FCs of patients with cancer. The interview transcripts were analyzed using qualitative hermeneutic analysis. This study revealed that living close to a cancer patient over the course of his or her illness affected many aspects of FCs lives in significant ways. Their experiences can be summarized with two major themes: (1) living in an ever changing life world and (2) balancing between conflicting interests and dilemmas. This study contributed to deeper insights into FC's experiences than previously reported in the literature.

Caring for dying and meeting death: experiences of Iranian and Swedish nurses

Objective:

Our world is rapidly becoming a global community, which creates a need to further understand the universal phenomena of death and professional caring for dying persons. This study thus was conducted to describe the meaning of nurses’ experiences of caring for dying people in the cultural contexts of Iran and Sweden.

Materials and Methods:

Using a phenomenological approach, phenomenon of caring for dying people was studied. Eight registered nurses who were working in oncology units in Tehran, Iran and eight registered nurses working in hospital and home care in North part of Sweden were interviewed. The interviews were analyzed using the principles of phenomenological hermeneutics.

Results:

The findings were formulated based on two themes included: (1) “Sharing space and time to be lost”, and (2) “Caring is a learning process.

Conclusions:

The results showed that being with dying people raise an ethical demand that calls for personal and professional response, regardless of sex, culture or context. The physical and organizational context must be supportive and enable nurses to stand up to the demands of close relationships. Specific units and teamwork across various personnel seem to be a solution that is missing in Iran.

Suffering and euthanasia: a qualitative study of dying cancer patients' perspectives

PURPOSE

Although intolerable suffering is a core concept used to justify euthanasia, little is known about dying cancer patients' own interpretations and conclusions of suffering in relation to euthanasia.

METHODS

Sixty-six patients with cancer in a palliative phase were selected through maximum-variation sampling, and in-depth interviews were conducted on suffering and euthanasia. The interviews were analyzed using qualitative content analysis with no predetermined categories.

RESULTS

The analysis demonstrated patients' different perspectives on suffering in connection to their attitude to euthanasia. Those advocating euthanasia, though not for themselves at the time of the study, did so due to (1) perceptions of suffering as meaningless, (2) anticipatory fears of losses and multi-dimensional suffering, or (3) doubts over the possibility of receiving help to alleviate suffering. Those opposing euthanasia did so due to (1) perceptions of life, despite suffering, as being meaningful, (2) trust in bodily or psychological adaptation to reduce suffering, a phenomenon personally experienced by informants, and (3) by placing trust in the provision of help and support by healthcare services to reduce future suffering.

CONCLUSIONS

Dying cancer patients draw varying conclusions from suffering: suffering can, but does not necessarily, lead to advocations of euthanasia. Patients experiencing meaning and trust, and who find strategies to handle suffering, oppose euthanasia. In contrast, patients with anticipatory fears of multi-dimensional meaningless suffering and with lack of belief in the continuing availability of help, advocate euthanasia. This indicates a need for healthcare staff to address issues of trust, meaning, and anticipatory fears.

Existential suffering in the palliative care setting: an integrated literature review

CONTEXT

Existential and spiritual concerns in relation to palliative end-of-life care have received increasing attention over the past decade.

OBJECTIVES

To review the literature specifically related to existential suffering in palliative care in terms of the significance of existential suffering in end-of-life care, definitions, conceptual frameworks, and interventions.

METHODS

A systematic approach was undertaken with the aim of identifying emerging themes in the literature. Databases using CINAHL (1980-2009), MEDLINE (1970-2009), and PsychINFO (1980-2009) and the search engine of Google Scholar were searched under the key words existential suffering, existential distress, existential pain, palliative and end of life care.

RESULTS

The search yielded a total of 156 articles; 32% were peer-reviewed empirical research articles, 28% were peer-reviewed theoretical articles, and 14% were reviews or opinion-based articles. After manually searching bibliographies and related reference lists, 64 articles were considered relevant and are discussed in this review. Overall analysis identifies knowledge of the following: 1) emerging themes related to existential suffering, 2) critical review of those identified themes, 3) current gaps in the research literature, and 4) recommendations for future research. Findings from this comprehensive review reveal that existential suffering and deep personal anguish at the end of life are some of the most debilitating conditions that occur in patients who are dying, and yet the way such suffering is treated in the last days is not well understood.

CONCLUSION

Given the broad range of definitions attributed to existential suffering, palliative care clinicians may need to be mindful of their own choices and consider treatment options from a critical perspective.

A Spider in the Web

Background: Palliative care is not a priority in developing countries. Hospice Africa Uganda (HAU), where nurses complete a course in clinical palliative care, is considered a model for other African countries. Aim: To explore the role of the palliative care nurse specialist (PCNS) in Uganda. Methods: This ethnographic field study uses observations, interviews, and group interviews. Participants: In total, 20 participants are included in this study. Result: The role of the palliative care nurse specialist is multifaceted. Beyond prescribing drugs, their role is to deliver holistic care. They encounter numerous challenges in their work, but they also have the possibility to improve the quality of the patient’s life.

Longing for ground in a ground(less) world: a qualitative inquiry of existential suffering

BACKGROUND

Existential and spiritual concerns are fundamental issues in palliative care and patients frequently articulate these concerns. The purpose of this study was to understand the process of engaging with existential suffering at the end of life.

METHODS

A grounded theory approach was used to explore processes in the context of situated interaction and to explore the process of existential suffering. We began with in vivo codes of participants' words, and clustered these codes at increasingly higher levels of abstractions until we were able to theorize.

RESULTS

Findings suggest the process of existential suffering begins with an experience of groundlessness that results in an overarching process of Longing for Ground in a Ground(less) World, a wish to minimize the uncomfortable or anxiety-provoking instability of groundlessness. Longing for ground is enacted in three overlapping ways: by turning toward one's discomfort and learning to let go (engaging groundlessness), turning away from the discomfort, attempting to keep it out of consciousness by clinging to familiar thoughts and ideas (taking refuge in the habitual), and learning to live within the flux of instability and unknowing (living in-between).

CONCLUSIONS

Existential concerns are inherent in being human. This has implications for clinicians when considering how patients and colleagues may experience existential concerns in varying degrees, in their own fashion, either consciously or unconsciously. Findings emphasize a fluid and dynamic understanding of existential suffering and compel health providers to acknowledge the complexity of fear and anxiety while allowing space for the uniquely fluid nature of these processes for each person. Findings also have implications for health providers who may gravitate towards the transformational possibilities of encounters with mortality without inviting space for less optimistic possibilities of resistance, anger, and despondency that may concurrently arise.

Living with incurable oesophageal cancer. A phenomenological hermeneutical interpretation of patient stories

PURPOSE

The study explores how patients diagnosed with incurable oesophageal cancer experience living with the illness, and provides insight into and an understanding of the patients' situation, reality and phenomena in their life world.

METHOD

The method takes a phenomenological-hermeneutic approach, inspired by the French philosopher Paul Ricoeur's narrative theory on mimesis as the structure and process of the method, and Ricoeur's theory of interpretation for the analysis of patient stories. The stories materialise from narrative interviews, and the phenomena of the patients' life world results in an analysis of these stories.

RESULTS

Through the analysis of the narrative interviews, phenomena of the patients' life world appear which are described in themes such as debut of the illness, denial, the person's own suspicion, existential turning point, despair, hope, the body, affirmation of irrevocable illness, acknowledgement of dying, life phenomena, relations and feeling of independence. The understanding of the patients' experiences is augmented and improved through a discussion of the themes in a philosophical perspective, drawing upon theoretical and philosophical viewpoints of Kierkegaard, Løgstrup, Merleau-Ponty, Ricoeur, Benner & Wrubel, and on empirical research.

CONCLUSIONS

Based on the phenomena in the ill person's life world brought about by analysis, it seems that incurably ill oesophageal cancer patients find themselves in a complex life situation, in which they need more than an objective estimate and fulfilment of need from hospital service. Our study illustrates some perspectives on the life situation of the incurably ill, which will contribute to the improved development of supportive care in nursing.

The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research

Spirituality and spiritual care are gaining increasing attention but their potential contribution to palliative care remains unclear. The aim of this study was to synthesize qualitative literature on spirituality and spiritual care at the end of life using a systematic ('meta-study') review. Eleven patient articles and eight with healthcare providers were included, incorporating data from 178 patients and 116 healthcare providers, mainly from elderly White and Judaeo-Christian origin patients with cancer. Spirituality principally focused on relationships, rather than just meaning making, and was given as a relationship. Spirituality was a broader term that may or may not encompass religion. A 'spirit to spirit' framework for spiritual care-giving respects individual personhood. This was achieved in the way physical care was given, by focusing on presence, journeying together, listening, connecting, creating openings, and engaging in reciprocal sharing. Affirmative relationships supported patients, enabling them to respond to their spiritual needs. The engagement of family caregivers in spiritual care appears underutilized. Relationships formed an integral part of spirituality as they were a spiritual need, caused spiritual distress when broken and were the way spiritual care was given. Barriers to spiritual care include lack of time, personal, cultural or institutional factors, and professional educational needs. By addressing these, we may make an important contribution to the improvement of patient care towards the end of life.

Soft tissue massage: early intervention for relatives whose family members died in palliative cancer care

AIM AND OBJECTIVES

This paper explores how bereaved relatives experienced soft tissue massage during the first four months after the death of a family member who was in palliative cancer care.

BACKGROUND

Death of a close family member or friend is recognised as being an emotional and existential turning point in life. Previous studies emphasise need for various support strategies to assist relatives while they are grieving.

DESIGN

Qualitative design.

METHOD

Eighteen bereaved relatives (11 women and seven men) received soft tissue massage (25 minutes, hand or foot) once a week for eight weeks. In-depth interviews were conducted after the end of the eight-week periods. Interviews were analysed using a qualitative descriptive content analysis method.

RESULTS

Soft tissue massage proved to be helpful and to generate feelings of consolation in the first four months of grieving. The main findings were organised into four categories: (1) a helping hand at the right time, (2) something to rely on, (3) moments of rest and (4) moments of retaining energy. The categories were then conceptualised into this theme: feelings of consolation and help in learning to restructure everyday life.

CONCLUSIONS

Soft tissue massage was experienced as a commendable source of consolation support during the grieving process. An assumption is that massage facilitates a transition toward rebuilding identity, but more studies in this area are needed.

RELEVANCE TO CLINICAL PRACTICE

Soft tissue massage appears to be a worthy, early, grieving-process support option for bereaved family members whose relatives are in palliative care.

Existential loneliness and end-of-life care: a systematic review

Patients with a life-threatening illness can be confronted with various types of loneliness, one of which is existential loneliness (EL). Since the experience of EL is extremely disruptive, the issue of EL is relevant for the practice of end-of-life care. Still, the literature on EL has generated little discussion and empirical substantiation and has never been systematically reviewed. In order to systematically review the literature, we (1) identified the existential loneliness literature; (2) established an organising framework for the review; (3) conducted a conceptual analysis of existential loneliness; and (4) discussed its relevance for end-of-life care. We found that the EL concept is profoundly unclear. Distinguishing between three dimensions of EL-as a condition, as an experience, and as a process of inner growth-leads to some conceptual clarification. Analysis of these dimensions on the basis of their respective key notions-everpresent, feeling, defence; death, awareness, difficult communication; and inner growth, giving meaning, authenticity-further clarifies the concept. Although none of the key notions are unambiguous, they may function as a starting point for the development of care strategies on EL at the end of life.

Older Norwegians' understanding of loneliness

This interpretive study explored older people's understanding of loneliness and what they considered appropriate and effective ways of dealing with it. Thirty elderly people were interviewed in-depth; 12 described themselves as "lonely" and 18 as "not lonely." We found a striking difference in the way "lonely" and "not lonely" people talked about loneliness. The "not lonely" participants described loneliness as painful, caused by the person's negative way of behaving and a state they should pull themselves out of. The "lonely" participants also described loneliness as painful, and gave more detailed descriptions of loneliness as disconnection from others, from their former home and from today's society. The "lonely" participants were more reserved and subdued in trying to explain loneliness, attributing it partly to themselves, but mostly to the lack of social contact with important others. Some felt able to handle their loneliness, while others felt unable to cope. This study underlines the importance of subjective experiences in trying to understand a phenomenon like loneliness and of developing support for lonely older people unable to cope on their own.

Caring for people at the end of life: Iranian oncology nurses' experiences

AIM

To explore the meaning of Iranian oncology nurses' experiences of caring for people at the end of life.

MATERIALS AND METHODS

A phenomenological hermeneutic approach was applied. Fifteen nurses working in oncology units were interviewed in 2007 regarding their experiences of caring for people at the end of life.

RESULTS

Participants experienced caring for people at the end of life as sharing space and time to be lost within an organizational context. This main theme was divided into three subthemes including being attentive to the dying persons and their families, being cared for by the dying persons and their families, and being faced with barriers.

CONCLUSION

The study suggests that the nurses' success in caring for people at the end of life is reliant on their interpersonal caring relationship. Facilitating such relationship requires the establishment of palliative care unit, incorporation of palliative care into undergraduate nursing studies, and cultural preparation through public education.

The existential impact of starting corticosteroid treatment as symptom control in advanced metastatic cancer

Treatment with corticosteroids often results in increased appetite, reduced nausea and improved well-being in patients with advanced metastatic cancer. Therefore, we have studied the existential impact of starting corticosteroid treatment as symptom control in this patient group using qualitative content analysis with both a descriptive and an interpretative focus. Ten patients were interviewed before and after 1 week of treatment with 4 mg betamethasone. Prior to treatment, patients reported distressing symptoms, deterioration and diminished autonomy, symbolising threat and death. Corticosteroid treatment produced symptom relief in the majority of the patients. They reported enhanced physical abilities and experienced feelings of a more normalized life and strengthened autonomy, symbolising health and hope. This transfer from threat to hope has important existential consequences in end-of-life care and should be addressed when communicating goals of treatment and care with the patient and family.

The spiritual meaning of pre-loss music therapy to bereaved caregivers of advanced cancer patients

Objective:

The aim of this study was to learn how music therapy sessions, held prior to the death of a loved one, impact spirituality in surviving caregivers of advanced cancer patients.

Method:

The method of naturalistic inquiry was used to investigate the spiritual meaning of pre-loss music therapy sessions. Bereaved caregivers of seven different patients, who had been receiving music therapy through a home-based hospice program, participated in individual open-ended interviews. Interviews were recorded, transcribed, and coded. Themes were organized as they emerged.

Results:

As caregivers reflected on their experiences in music therapy, they reported autonomous joy (music therapy affected the caregiver directly) and empathic joy (caregivers' joy was based in remembering seeing the patient happy in music therapy). They also noted feelings of empowerment due to the ways they felt they had contributed in the care of the patients through music therapy. The caregivers were found to engage in processes of reflection that inspired these spiritual themes: reflection on the present (connectedness), reflection on the past (remembrance), and reflection on the future (hope). They referred to the ways that the music therapy sessions helped them find connection with self, others (through bringing their loved ones “back to life” and have a “renewal of self”), and the “beyond”; and that times in music therapy brought them happy memories and sentiments of hope. Meaning through transcendence was found to be the overarching trend in this study, as caregivers were lifted from remorse into heightened sense of meaning and gained “airplane views” of their lives.

Significance of results:

Pre-loss music therapy can potentially assist caregivers during times of bereavement, as they retain memories of joy and empowerment, rather than memories of pain and distress, and find meaning through transcendence.

The existential experiences of receiving soft tissue massage in palliative home care--an intervention

BACKGROUND

Soft tissue massage is currently used in palliative care for the relief of anxiety and pain. Only few studies have focused on patients' deeper experience of receiving the massage.

AIM

The purpose of this study was to explore how patients with cancer in palliative home care experienced soft tissue massage.

MATERIALS AND METHODS

Twenty-two patients received soft tissue massage (hand or foot) nine times over a period of 2 weeks. Each session lasted for 25 min. Following the last massage session, a qualitative interview was conducted. The analysis was performed using a hermeneutic approach.

FINDINGS

Soft tissue massage generated feelings of existential respite with perceptions of being released from illness for a while. Two categories constituted the basis of the experiences: (1) "an experience of thoughtful attention" and (2) "a sensation of complete tranquility" resulting in the overarching theme "A time of existential respite."

CONCLUSION

The patients experienced the massage to give meaning and to be important as it generated feelings of an inner respite.

RELEVANCE TO CLINICAL PRACTICE

Soft tissue massage appears to be an appreciated source of support to dying patients in palliative home care. The method is easy to comprehend and relatively short (25 min) which may imply that it is a suitable complement in nursing care for this patient group.

Coping strategies in the presence of one's own impending death from cancer

An incurable cancer is a threat to life itself. This study focused on how native-born Swedes, who define themselves as nonreligious, actually reflect and act when they try to create helpful strategies in the presence of their own impending deaths and how the strategies serve their purposes. Twenty patients were interviewed in depth. The patients were enrolled in an advanced hospital-based home care team. The interviews were taped, transcribed and analyzed with a qualitative, hermeneutic interpretative method. The informants' efforts to develop useful strategies to restrain death could be symbolized as a cognitive and emotional pendulum, swinging between the extremes of life and death. During the swings of the pendulum, the informants used every means available: their own resources, other people, animals, nature, a transcendent power, hope, imagination and magical thinking. They strove to find factors that fitted their conceptual system and supported their inner balance and structure, all to keep death at a discreet distance and preserve their links to life. These links were togetherness, involvement, hope and continuance, and they served as a shield against hurtful feelings connected to their impending death. The new knowledge about how strategies in the presence of one's own impending death can develop and be used is perhaps the most novel and clinically relevant contribution of this study.

The meaning of quality of life: narrations by patients with incurable cancer in palliative home care

OBJECTIVE

The objective of this qualitative study was to elucidate the meaning of quality of life as narrated by patients with incurable cancer approaching death in palliative home care in Sweden.

METHODS

To gain a deeper understanding of what quality of life means for dying patients, data were collected from narrative interviews with eight patients in their homes in 2004-2006. Qualitative content analysis was used to interpret the meaning regarding quality of life.

RESULTS

Three main themes were found: being in intense suffering, having breathing space in suffering, and being at home. Living with incurable cancer at the end of life was experienced as living in physical distress as the body became incapacitated by unexpected physical complications. This incapacity had consequences on patients' psychological, social, and existential well-being. As the complication phase abated, the patients experienced that they regained hopefulness and had time to reflect on existential issues. Patients were provided affirmative care at home from family caregivers and the palliative home care team.

SIGNIFICANCE OF RESULTS

This study shows that it is feasible to perform individual interviews with patients approaching death and elucidate the meaning of patients' quality of life in palliative home care. Patients oscillate between being in intense suffering and having breathing space in this suffering, which somewhat opposes the traditional picture of a continuous linear deterioration. Being cared for at home by family caregivers and health care professionals provided a sense of independency and security. Being at home safeguards patients' entire life situation and increases quality of life.