The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives

A scoping review of family experience and need during end of life care in intensive care

AIM

To scope systematically and collate qualitative studies on family experience and need during end of life care in intensive care, from the perspective of family members.

DESIGN

Scoping review of qualitative research.

METHODS

Standardized processes of study identification, data extraction and data synthesis were used. Multiple bibliographic databases were accessed during 2011 and updated in 2013.

RESULTS

From an initial 876 references, 16 studies were identified for inclusion. These were predominantly single site, North American studies that explored issues relating to the temporal stages in the end of life trajectory and the requirement for information and emotional support at end of life. With a strong focus on family need and experience during the transition from active treatment to end of life care, more work is required to understand how doctors and nurses can support families from treatment withdrawal through to death.

Measuring the quality of dying and death in the pediatric intensive care setting: the clinician PICU-QODD

CONTEXT

In the pediatric intensive care setting, an accurate measure of the dying and death experience holds promise for illuminating how critical care nurses, physicians, and allied psychosocial staff can better manage end-of-life care for the benefit of children and their families, as well as the caregivers.

OBJECTIVES

The aim was to assess the reliability and validity of a clinician measure of the quality of dying and death (Pediatric Intensive Care Unit-Quality of Dying and Death 20 [PICU-QODD-20]) in the pediatric intensive care setting.

METHODS

In a retrospective cohort study, five types of clinicians (primary nurse, bedside nurse, attending physician, and the psychosocial clinician and critical care fellow most involved in the case) were asked to complete a survey for each of the 94 children who died over a 12 month period in the pediatric intensive care units of two children's hospitals in the northeast U.S. Analyses were conducted within type of clinician.

RESULTS

In total, 300 surveys were completed by 159 clinicians. Standard item analyses and substantive review led to the selection of 20 items for inclusion in the PICU-QODD-20. Cronbach alpha for the PICU-QODD-20 ranged from 0.891 for bedside nurses to 0.959 for attending physicians. For each type of clinician, the PICU-QODD-20 was significantly correlated with the quality of end-of-life care and with meeting the family's needs. In addition, when patient/family or team barriers were encountered, the PICU-QODD-20 score tended to be significantly lower than for cases in which the barrier was not encountered.

CONCLUSION

The PICU-QODD-20 shows promise as a valid and reliable measure of the quality of dying and death in pediatric intensive care.

The quality of dying and death in cancer and its relationship to palliative care and place of death

CONTEXT

Health care is increasingly focused on end-of-life care outcomes, but relatively little attention has been paid to how the dying experience is subjectively evaluated by those involved in the process.

OBJECTIVES

To assess the quality of death of patients with cancer and examine its relationship to receipt of specialized palliative care and place of death.

METHODS

A total of 402 deaths of cancer patients treated at a university-affiliated hospital and home palliative care program in downtown Toronto, Ontario, Canada were evaluated by bereaved caregivers eight to 10 months after patient death with the Quality of Dying and Death (QODD) questionnaire. Caregivers also reported on bereavement distress, palliative care services received, and place of death.

RESULTS

Overall quality of death was rated "good" to "almost perfect" by 39% and "neither good nor bad" by 61% of caregivers. The lowest QODD subscale scores assessed symptom control (rated "terrible" to "poor" by 15% of caregivers) and transcendence over death-related concerns (rated "terrible" to "poor" by 19% of caregivers). Multivariable analyses revealed that late or no specialized palliative care was associated with worse death preparation, and home deaths were associated with better symptom control, death preparation, and overall quality of death.

CONCLUSION

The overall quality of death was rated positively for the majority of these cancer patients. Ratings were highest for home deaths perhaps because they are associated with fewer complications and/or a more extensive support network. For a substantial minority, symptom control and death-related distress at the end of life were problematic, highlighting areas for intervention.

Correlates of a good death and the impact of hospice involvement: findings from the national survey of households affected by cancer

PURPOSE

Knowing how to improve the dying experience for patients with end-stage cancer is essential for cancer professionals. However, there is little evidence on the relationship between clinically relevant factors and quality of death. Also, while hospice has been linked with improved outcomes, our understanding of factors that contribute to a "good death" when hospice is involved remains limited. This study (1) identified correlates of a good death and (2) provided evidence on the impact of hospice on quality of death.

METHODS

Using data from a survey of US households affected by cancer (N = 930, response rate 51 %), we fit regression models with a subsample of 158 respondents who had experienced the death of a family member with cancer. Measures included quality of death (good/bad) and clinically relevant factors including: hospice involvement, symptoms during treatment, whether wishes were followed, provider knowledge/expertise, and compassion.

RESULTS

Respondents were 60 % female, 89 % White, and averaged 57 years old. Decedents were most often a respondent's spouse (46 %). While 73 % of respondents reported a good death, Hispanics were less likely to experience good death (p = 0.007). Clinically relevant factors, including hospice, were associated with good death (p < 0.05)--an exception being whether the physician said the cancer was curable/fatal. With adjustments, perceptions of provider knowledge/expertise was the only clinical factor that remained associated with good death.

CONCLUSIONS

Enhanced provider training/communication, referrals to hospice and greater attention to symptom management may facilitate improved quality of dying. Additionally, the cultural relevance of the concept of a "good death" warrants further research.

Discussing prognosis and end-of-life care in the final year of life: a randomised controlled trial of a nurse-led communication support programme for patients and caregivers

INTRODUCTION

Timely communication about life expectancy and end-of-life care is crucial for ensuring good patient quality-of-life at the end of life and a good quality of death. This article describes the protocol for a multisite randomised controlled trial of a nurse-led communication support programme to facilitate patients' and caregivers' efforts to communicate about these issues with their healthcare team.

METHODS AND ANALYSIS

This NHMRC-sponsored trial is being conducted at medical oncology clinics located at/affiliated with major teaching hospitals in Sydney, Australia. Patients with advanced, incurable cancer and life expectancy of less than 12 months will participate together with their primary informal caregiver where possible. Guided by the self-determination theory of health-behaviour change, the communication support programme pairs a purpose-designed Question Prompt List (QPL-an evidence-based list of questions patients/caregivers can ask clinicians) with nurse-led exploration of QPL content, communication challenges, patient values and concerns and the value of early discussion of end-of-life issues. Oncologists are also cued to endorse patient and caregiver question asking and use of the QPL. Behavioural and self-report data will be collected from patients/caregivers approximately quarterly for up to 2.5 years or until patient death, after which patient medical records will be examined. Analyses will examine the impact of the intervention on patients' and caregivers' participation in medical consultations, their self-efficacy in medical encounters, quality-of-life, end-of-life care receipt and quality-of-death indicators.

ETHICS AND DISSEMINATION

Approvals have been granted by the human ethics review committee of Royal Prince Alfred Hospital and governance officers at each participating site. Results will be reported in peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12610000724077.

A randomised controlled trial on the efficacy of advance care planning on the quality of end-of-life care and communication in patients with COPD: the research protocol

INTRODUCTION

Recent research shows that advance care planning (ACP) for patients with chronic obstructive pulmonary disease (COPD) is uncommon and poorly carried out. The aim of the present study was to explore whether and to what extent structured ACP by a trained nurse, in collaboration with the chest physician, can improve outcomes in Dutch patients with COPD and their family.

METHODS AND ANALYSIS

A multicentre cluster randomised controlled trial in patients with COPD who are recently discharged after an exacerbation has been designed. Patients will be recruited from three Dutch hospitals and will be assigned to an intervention or control group, depending on the randomisation of their chest physician. Patients will be assessed at baseline and after 6 and 12 months. The intervention group will receive a structured ACP session by a trained nurse. The primary outcomes are quality of communication about end-of-life care, symptoms of anxiety and depression, quality of end-of-life care and quality of dying. Secondary outcomes include concordance between patient's preferences for end-of-life care and received end-of-life care, and psychological distress in bereaved family members of deceased patients. Intervention and control groups will be compared using univariate analyses and clustered regression analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from the Medical Ethical Committee of the Catharina Hospital Eindhoven, the Netherlands (NL42437.060.12). The current project provides recommendations for guidelines on palliative care in COPD and supports implementation of ACP in the regular clinical care.

CLINICAL TRIAL REGISTRATION NUMBER

NTR3940.

Patient values and preferences for end-of-life treatments: are values better predictors than a living will?

BACKGROUND

Advance care planning is widely considered important for good treatment decision making. Patient values have been proposed as superior to standard living wills as guides to end-of-life (EOL) care decisions on behalf of decisionally incapacitated patients. Little research has examined whether values outperform living wills as predictors of treatment preferences.

OBJECTIVE

The study aimed to test whether patient values are associated with treatment preferences, compare values and preferences to responses from a standard living will, and determine whether some values are better predictors than others.

DESIGN

Community-dwelling elderly men and women (n=304) were interviewed in their homes by telephone. The interview consisted of an eight-item EOL values scale, a standard living will question, preferences for four life-prolonging treatments in each of six scenarios, and sociodemographic questions.

RESULTS

Principal components analysis of the EOL values revealed two factors: (1) dignity, pain management, and reluctance to burden others; and (2) religiosity and desire for longevity and following family wishes. In regression analyses, stronger preferences for life-prolonging treatments were correlated with higher scores on factor 1 and lower scores on factor 2. But when living will responses were also entered into the regression model, only religiosity, longevity, and following family wishes predicted treatment preferences independently of the living will responses.

CONCLUSIONS

Providing better guidance than a living will in determining a patient's EOL treatment preferences are (1) knowledge about a patient's religiosity, (2) patient's wishes for longevity, and (3) patient's wishes for following family preferences. Wishes for dignity and pain management and reluctance to burden others do not offer better guidance than a living will.

Early Detection of Ovarian Tumors Using Ultrasound

Ovarian cancer can be treated with a very good prognosis if detected in the early stages, but not after it has advanced. Transvaginal ultrasound is capable of identifying changes in ovarian size and structure, and thereby detects early ovarian malignancies. This view has generated four major trials on transvaginal ultrasound detection: the Kentucky, PLCO, UKCTOCS, and SCSOCS trials. Each is sufficiently different to warrant examination. The Kentucky, UKCTOCS and SCSOCS trials report a shift to early stage detection. The Kentucky trial reports a survival benefit, while follow-up survival analysis is pending in the UKCTOCS and SCSOCS trials. Details of these trials are presented including definitions, inclusions/exclusions, analytic structure (intention-to-treat vs per protocol), performance (sensitivity, specificity, positive predictive value and negative predictive value), extent of screening-related treatment, time from screening to treatment, length of follow-up and survival versus mortality analysis. Questions are answered here about effectiveness, application, prevalence, cost and the potential for harm.

Factors affecting the improvement of quality of dying of terminally ill patients with cancer through palliative care: a ten-year experience

BACKGROUND

Achieving a good death is the ultimate goal of palliative medicine. Yet, very few studies have investigated factors affecting improvement in quality of dying. We therefore conducted a study to evaluate these factors in terminally ill Taiwanese cancer patients treated in a multidisciplinary palliative care unit.

METHODS

We included data from terminally ill patients with cancer admitted to the Hospice and Palliative Care Unit in the National Taiwan University Hospital from 2000 to 2009. Quality of dying was assessed by patients' multidisciplinary team at admission and after death using the Good Death Scale and the Audit Scale. We used multivariable regression to assess the association between patient factors, including gender, age, diagnosis, days of hospitalization, calendar year of admission, Good Death score at admission, and process of care scores for physical care, physician-assessed autonomy, emotional support, communication, continuity of life, and physician-reported rate of closure, with the quality of dying.

RESULTS

Multivariate regression analysis identified lower Good Death score at admission, lower age 40-65 years, longer unit length of stay (>7 days), higher physician-assessed autonomy, better physician-assessed emotional support, and better physician-reported rate of closure as positively related (all p<0.0001) with improvement in good death scores.

CONCLUSION

In this study in a Taiwanese palliative care unit; we found that late referral to the unit and low physician-assessed autonomy were key factors negatively affecting quality of dying. Earlier truth-tellling and end-of-life care discussions between physicians and patients might improve the quality of dying in this population.

Concept Analysis of Good Death in Terminally Ill Patients

The purpose of this concept analysis of good death was to examine the attributes of a good death and explore the changes of the concept over time and its impact on terminally ill patients. The method used for this analysis was the Rodgers’ evolutionary method. A literature search was completed using Medline Ovid and Journal Storage (JSTOR).The findings describe the evolution of the good death concept over time from the prehistoric era followed by premodern, modern, and postmodern times. In addition, information is presented about surrogate terms, attributes, antecedents, and consequences associated with good death followed by analysis and discussion of the findings. General attributes of a good death include pain and symptom management, awareness of death, patient’s dignity, family presence, family support, and communication among patient, family, and health care providers.

Measuring family satisfaction with care and quality of dying in the intensive care unit: does patient age matter?

RATIONALE

Few studies have examined the role of patient age on family experiences of end-of-life care.

OBJECTIVES

To assess measurement characteristics of two family-assessed questionnaires across three patient age groups.

METHODS

Four hundred and ninety-six patients who died in an intensive care unit (ICU) at a single hospital were identified and one family member per patient was sent two questionnaires: 1) Family Satisfaction in the ICU (FS-ICU); and 2) Quality of Dying and Death (QODD). Two hundred and seventy-five surveys were returned (55.4%). We analyzed three age groups: <35, 35-64, and ≥65 years. Differences were evaluated using χ(2) tests to evaluate ceiling, floor, and missing responses; Kruskal-Wallis tests to compare median scores on items and total scores; and linear regression controlling for patient sex, race, diagnosis, and family-member sex, race, education, and relationship to provide adjusted comparisons of total and subscale scores.

RESULTS

Measurement characteristics varied by age groups for both questionnaires. Missing values and floor endorsements were more common for the younger age groups for six items and one overall rating score. Ceiling endorsements were more common for the older group for 11 items. Fifteen items and four total scores were significantly higher in the older group.

CONCLUSIONS

The FS-ICU and QODD questionnaires performed differently across patient age groups. Assessments of family satisfaction and quality of dying and death were higher in the oldest group, particularly in the area of clinician-family communication. Studies of the dying experience of older adults may not generalize to patients of other ages, and study instruments should be validated among different age groups.

How do cancer patients receiving palliative care at home die? A descriptive study

CONTEXT

Data regarding the circumstances of the process of death of terminally ill patients followed at home are lacking.

OBJECTIVES

The aim of this study was to describe the characteristics and assess the circumstances of the process of death of terminally ill patients followed at home.

METHODS

This was a prospective survey to assess the dying process of advanced cancer patients followed at home. Within a week after death, the principal caregiver was interviewed. Information from the palliative home care team and the caregiver about expectation of death, time of death, professional and nonprofessional people present at time of death, emergency admission to hospital, and administration of drugs to resuscitate was gathered. The principal clinical issues in the last two hours also were recorded.

RESULTS

In total, 181 of 222 caregivers provided information. Most deaths were expected. Palliative home care team physicians and nurses visited the patient on the day of death but were occasionally present at the moment of death. More than three people were generally present at time of death. More than two-thirds of patients died peacefully, without apparent suffering, and 35.7% of them received palliative sedation before dying. In the last two hours, the most frequent clinical issues were ranked as death rattle, dyspnea, and agitation. In 10 cases, emergency drugs for resuscitation were administered.

CONCLUSION

This study has shown how advanced cancer patients die at home and that palliative home care may be helpful in allowing a death at home, particularly when relatives are actively involved.

Effects of a patient/family-centered practice change on the quality and cost of intensive care: research protocol

AIM

This paper is a description of a protocol for studying the impact of a patient/family-centered, evidence-based practice change on the quality, cost and use of services for critically ill patients at the end of life.

BACKGROUND

International attention currently is focused on the quality and cost/use of intensive care services. Empirical literature and expert opinion suggest that early, enhanced communication among the clinical team and the patient and family results in higher quality and less costly care at the end of life.

DESIGN

Our Medical Intensive Care Unit practice change involves three components: teaching sessions for all Registered Nurses and physicians assigned to the unit; patient/family meetings held in 72 hours of the patient's admission to the unit; and formal documentation to support communication among clinicians. Ethical approval was obtained in April 2009. A two-group post-test design is used, with one group comprising patients hospitalized before the practice change and their families, and the second group of patients/families after the practice change. Data comprise medical record information and families' responses to surveys. Final analytic models will result from multivariable regression techniques.

DISCUSSION

The study represents translational research in that interventions are brought to the bedside to reach the people for whom the interventions were designed. The practice change is likely to endure after the study because our research team is composed of both clinicians and scientists. Also, direct care clinicians endorse and are responsible for the practice change.