Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity

[The main caregiver of oncologic terminally ill patient, repercussions of this task]

OBJECTIVES

to identify the profile of the caregivers of terminally ill patient, to inquire the activities, changes and difficulties. The researchers applied a questionnaire. From all the 53 caregivers, 48 were female. 92% of the caregivers were relative to the patient. Despite of the financial problems, their relationship between caregiver and patient improved. The hygiene cares, feeding, medication were responsibility of the caregiver. The activities developed increased their amount of job, negative physical and psychical repercussions appeared. 60% of the caregivers answered that the most convenient place of the patient's death was the hospital, 40% chose home. There is a distinction between the routine of care and the death of the patient; the caregivers in fact take care of life.

Strangers, Patients, Monsters, Jailers, or Children: How South African Caregivers View Their Partners with Manganese Poisoning

Manganese poisoning (MP) is one of many chronic, degenerative conditions that result in spousal caregiver stress. Partners who were once fully functioning become strangers to those who love them. In time, spousal caregivers may come to view their erstwhile partners as patients, jailers, monsters, or bratty children. We explore spousal caregiver perceptions of loved ones with MP, based on the narrated experiences of five full-time South African carers and develop a typology of carer experiences, which contributes to an understanding of manganese poisoning, in particular, and to caregiving theory, in general. The findings contribute to practice by providing service providers with a rich understanding of carer stress and coping, in general, and the stress of those caring for partners with MP, in particular. Such richer understanding should extend service provider empathy and encourage appropriate, supportive intervention.

Interviewing family caregivers: implications of the caregiving context for the research interview

Family caregiving tends to involve strong and often competing emotional experiences. Most of our knowledge of caregiving stems from interview research, much of it cross-sectional in nature. In this article we explore the implications of interviews as a research method for understanding caregiving. Specifically, we address difficulties in interpreting participants' talk about caregiving when this talk is simultaneously an articulation of experience and an attempt to cope with that experience. Either uncritically accepting accounts as reflective of experience, without considering the role of coping, or making assumptions about the success of caregiver coping in this context, might be erroneous. Our own experiences of interviewing family caregivers in different research projects will be drawn upon as examples. We conclude by questioning the ability to draw conclusions about caregiving and/or caregiver coping based solely on interview research, and call for greater integration of observational and longitudinal methods in family caregiving research.

Next-of-kin caregivers in palliative home care--from control to loss of control

AIM

This paper is a report of a study to describe situations influencing next-of-kin caregivers' ability to manage palliative care in the home.

BACKGROUND

Palliative home care often involves major resources from next-of-kin, municipal and county personnel. Next-of-kin caregivers' situation is depicted as so demanding and exhausting that it can affect their mental health and limit their ability to continue as a caregiver.

METHODS

A qualitative study using the Critical Incident Technique was conducted. Nine next-of-kin caregivers from palliative home care were strategically chosen and data were collected using audiotaped interviews in 2005.

FINDINGS

The analysis resulted in two main areas: 'Maintaining control' and 'Losing control'. Next-of-kin caregivers wanted to maintain control over their lives by being continuously available 24 hours a day and by supporting and taking complete responsibility for all of the patient's needs. They lost this control when professional assistance was lacking and they described feelings of inadequacy when their physical energy or time was insufficient. They felt incapable as the patient's physical or mental persona metamorphosed or as serious symptoms developed that they could not control.

CONCLUSION

Next-of-kin caregivers and the patients must feel free to choose where palliative home care will be provided and that their choice at any time can be re-evaluated, due to insecurity or workload changes. When planning for palliative care, they should be informed that having only one caregiver reduces the chances of completing palliative care in the home.

End-of-life care in Italy: personal experience of family caregivers. A content analysis of open questions from the Italian Survey of the Dying of Cancer (ISDOC)

OBJECTIVE

This study aims at describing the emotional and practical experience of a representative sample of Italian non-professional caregivers when caring for a terminally ill family member and is part of the 'Italian Survey of the Dying of Cancer', which involved 2000 adult cancer deaths representative of the whole country.

METHODS

Information on patients' experience was gathered from non-professional caregivers by an interview. A specific question was asked about the caregivers' emotional and practical experiences while assisting a terminally ill relative. A content analysis of the open question on caregivers' perceptions was performed on transcribed answers. Three researchers independently generated categories. Subsequently, areas where they differed were reconsidered and an interpretation was agreed upon.

RESULTS

Valid interviews were obtained from 1231 non-professional caregivers. Answers were classified according to the perception of the experience as positive (33.1%), negative (65.1%) or neutral (1.8%).

CONCLUSION

Assisting a family member with cancer in his/her last three months of life is a very strong physical and mental stress for the caregiver. In some cases, this experience is nevertheless perceived as an evolution chance. Health-care providers should need to develop programs to ensure that family caregivers' needs for information and support are given great importance.

Impact of perception of socioeconomic burden on advocacy for patient autonomy in end-of-life decision making: a study of societal attitudes

We investigated the impact of perception of socioeconomic burden on beliefs regarding a patient's autonomy in end-of-life (EOL) decision making. We also sought to identify the characteristics of individuals who advocate patient autonomy and their attitudes toward other EOL issues. A total of 1055 individuals from the Korean general population were interviewed through a telephone survey using a structured questionnaire that was designed to investigate public attitudes toward various EOL issues. Of 1019 individuals included in the analysis, 635 (62.3%) specified the patient and 221 (21.7%) the family, when asked who is the appropriate decision maker in terms of EOL decisions in the absence of perception of socioeconomic burden. In contrast, the numbers were 458 (44.9%) and 500 (49.1%), respectively, if substantial burden was assumed. Respondents who favoured the patient's right to make decisions regardless of perception of socioeconomic burden numbered only 312 (30.6%) and were likely to be younger and have knowledge of hospice than who favoured family decision. Former group also favoured the disclosure of terminal illness to patients, withholding life-sustaining treatment, and preparation of advanced directives. Societal attitudes toward patient autonomy were significantly influenced by perception of socioeconomic burden. Open and balanced discussion about burden to family and adequate welfare support are thus suggested.

Health-related quality of life in significant others of patients dying from lung cancer

This study compares health-related quality of life (HRQOL) in significant others of patients dying from lung cancer, with a general population sample. Further, it explores the course of HRQOL from diagnosis (T1), at a time point close to the patient's death (T2), and six months after the patient's death (T3). The group comparisons at T1 showed that the significant others scored significantly lower on the scales in the mental domain compared with a general population sample. These results were the same at T3, when the significant others also scored lower on most of the scales in the physical and social domains. In the longitudinal analyses, there were significant changes in four scales, and three patterns of change were identified: a decrease-increase pattern for 'self-rated health' and 'positive affect'; a constant decrease pattern for 'family functioning'; and a decrease-stable pattern for 'satisfaction with family functioning'. Thus, living with inoperable lung cancer in the family and then facing the death of a family member affects most of the HRQOL dimensions.

Palliative care for cancer patients in a primary health care setting: Bereaved relatives' experience, a qualitative group interview study

Background

Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited.

The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary care setting to explore barriers and facilitators for delivery of good palliative home care.

Methods

Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark.

Results

Three main categories of experience were identified: 1) The health professionals' management, where a need to optimize was found. 2) Shared care, which was lacking. 3) The relatives' role, which needs an extra focus.

Conclusion

Relatives experience insufficient palliative care mainly due to organizational and cultural problems among professionals. Palliative care in primary care in general needs improvement and attention should be drawn to the "professionalization" of the relatives and the need to strike a balance between their needs, wishes and resources in end-of-life care and bereavement.

Populations who die without specialist palliative care: does lower uptake equate with unmet need?

BACKGROUND

In palliative care, the target population (all people with life-limiting illnesses and their family/caregivers) and the complexity of their needs from diagnosis to bereavement should define the subpopulation who access specialist palliative care services (SPCS). Have caregivers of patients who have not accessed SPCS had their needs met?

METHODS

As part of a broader state-wide randomized face-to-face population health survey over six years (18,224 interviews, 71% response), questions were asked of people bereaved in the previous five years when someone close to them died an ;expected' death (39% of respondents). Questions included respondent demographics, the diagnosis of the deceased and, for one year, whether SPCS was of benefit (if used) or needed (if not used). Differential uptake rates were calculated for diagnosis, income, country of birth and age and 2 x 2 tables reflecting the accuracy of match of service with caregiver needs were generated for each group (accuracy = true positives + true negatives/total) *100.

RESULTS

Uptake of SPCS was significantly lower in people with a non-cancer diagnosis (40% versus 62%; P = 0.0001), lower income (56% versus 61%; P = 0.0006) and people born where English was not the first language (52% versus 58%; P = 0.0096). The only subgroup where the accuracy of matching between palliative care service uptake and identified needs was lower than the overall average (83%) was where cancer was not the life-limiting illness (69%; cancer 86%).

DISCUSSION

SPCS under utilization has previously been described in the population subgroups explored in this study and assumed to equal unmet needs and poorer outcomes. Caregiver responses suggest that, except for people with a non-cancer diagnosis, lack of service uptake may not represent unmet needs. These results are limited to people with caregivers.

Considerations for psychosocial support following burn injury—A family perspective

As part of a larger study involving burned adults and parents of burned children, family members were asked for their views regarding the impact of burn on themselves and the family (N=50). The aim is to describe the range of psychosocial issues that psychosocial support programmes may need to address. This paper reports on the content analysis of specifically designed self-completion questionnaires. The results reveal commonalities within support needs across the three study groups (siblings, children, and partners). These are recommended as key elements in a family support programme: (i) normalising of family member's reactions to the burn. (ii) Advice, support, and information regarding scar permanence, realistic outcome expectations, acceptance of altered appearance, and potential after-effects of burn. (iii) Support in understanding how a burned individual may change or respond following injury and advice regarding constructive methods of coping with altered family dynamics and after-effects of burn. (iv) Advice to enable family members and their burned relative to effectively deal with potentially uncomfortable social encounters.

A family's beliefs about cancer, dying, and death in the end of life

The purpose of this case study was to describe the beliefs over time of a Swedish family and individual family members about cancer and death and how these beliefs affected their daily lives. Data were collected over 10 months using interviews, conversations, and diary notations. The beliefs were aggregated into eight main beliefs and four themes: Cancer is a deadly threat/death is a liberator, death can be held at bay/death can be lived near, dying is done alone/dying should not be done alone, and life has an end/life is endless. These beliefs appear to oscillate between seemingly contrasting poles. Some beliefs were shared by all family members, whereas others were described by only one or more members of the family. The complexity of daily life in families experiencing life-shortening illness underscores the need of individualized nursing care with openness to difference and collaboration as guiding principles.

Older Carers in Ageing Societies: An Evaluation of a Respite Care Program for Older Carers in Western Australia

The Australian Red Cross Older Carers Program was developed in 2003 to support the unique needs of "older carers" aged 65 and older (50 if Indigenous) who care for a person (a care recipient, usually a family member) aged 18 or older who have a permanent disability. The aim of the program was to provide intensive case planning, management, and volunteer support that would assist older carers to more readily access respite and continue their caring role in the home. To help achieve this end, ongoing individualised and holistic assistance involving older carers in decision making was an integral component of the Older Carers Program, as was the use of regular home visits by program staff. The Older Carers Program evaluation was both a process and outcome evaluation. Much of the evaluation research focused on the extent to which it had met its stated aims and objectives. However, because the program was quite new and innovative there was a significant further focus upon the processes and activities within the program. At the time the evaluation research was conducted (May 2005), the program had been in operation for 22 months. The population group was identified as those persons (older carers) who had been part of the program between July 2003 and March 2005. Of the 96 older carers who had accessed the program in the specified period, 62 agreed to participate in our research. The methodology consisted of an audit or the program database, in-depth interviews with older carers, and contextual data collection involving program staff and other stakeholders.

A support group programme for relatives during the late palliative phase

This study describes an intervention where relatives were invited to take part in a support group programme during the late palliative phase of their family member. The purpose was to describe their experiences of the support group programme and the subsequent impact on their lives as relatives of a terminally ill person. Qualitative interviews were chosen as the data collection method. The analysis was inspired by the phenomenological method as described by Giorgi (1989). The relatives' experiences were categorised into six key constituents: confirmation; insight into the gravity of the illness; sense of belonging created by similar experiences; participation in the care system; being able to rest; and strength to provide support for the patient. These six constituents resulted in a sense of safety in relation to the patient, the illness, the nursing staff and the care unit. The study's findings show that interventions of this kind may be integral to the relatives' ability to handle their situation when caring for a terminally ill family member.

Caring for dying patients outside special palliative care settings: experiences from a nursing perspective

The aim of the study was to describe nurses' experiences in caring for gravely ill and dying patients outside special palliative care settings. Tape-recorded qualitative interviews were conducted with a total of nine nurses in primary home care, community care and hospitals. The interviews were analysed according to phenomenological methodology, which resulted in the three common structures: ambition and dedication, everyday encounters, and satisfaction/dissatisfaction. In the 'everyday encounters' structure, the following key constituents emerged: responsibility, cooperation, experience and knowledge, feelings, and time and resources. The results describe the nurses' high ambitions to give dying patients and their relatives high-quality care. Despite this, they experienced greater or lesser degrees of dissatisfaction because of insufficient cooperation, support, time and resources. They experienced satisfaction through contact with patients and relatives, functioning collegial cooperation, and the knowledge, experience and personal growth the care had given them. The results indicate that nurses need the resources such as time, improved methods of communication and cooperation as well as more support in order to give quality palliative care and achieve satisfaction with the outcome. The need for discussion about the conditions for giving palliative care outside the hospices and other special palliative care settings is also elucidated.

QOLLTI-F: measuring family carer quality of life

BACKGROUND

The primary goal of palliative care is to optimize the quality of life (QOL) of people living with a life-threatening illness and that of their families. While there have been important advances in measurement of the QOL of palliative care patients, little attention has been paid to the QOL of their carers (family caregivers). To develop and deliver the most effective services to these carers, their QOL needs to be measured with acceptable and psychometrically sound instruments that have content validity.

METHODS

This study reports three phases of the development and testing of such a measure: QOLLTI-F, Quality of Life in Life Threatening Illness--Family Carer Version, simultaneously in English and French. Participants were carers from 12 Canadian palliative care services who were asked to complete QOLLTI-F on three occasions.

RESULTS

The final version of QOLLTI-F consists of 16 items. It was deemed acceptable by the vast majority of carers and a longer, 24-item version was completed in a median of 12 min. Content validity was assured by inclusion of all domains reported by carers to be important to their QOL: state of carer, patient wellbeing, quality of care, outlook, environment, finances and relationships. Construct validity was demonstrated, as principal components analysis indicated that the 16 items did indeed reflect these seven domains. Furthermore, the seven domain scores predicted 53% of the variance in global QOL, although the QOLLTI-F Total score predicted less well (43%). The test-retest reliability for the QOLLTI-F Total score was 0.77-0.80 and ranged from 0.50 to 0.79 for the seven domain scores. All QOLLTI-F scores were shown to be significantly different between days the carers considered bad, average and good, demonstrating responsiveness to change, with the exception of the Financial Concerns submeasure, which did not distinguish between average and good days.

CONCLUSIONS

QOLLTI-F is unique in that in measuring one person's QOL (the carer's) it includes their perception of the condition of another (the patient). This attests to the close relationship between the two. It is also unique in that its content is derived from a qualitative study asking carers what is important to their own QOL, rather than focusing on the changes or burdens related to caregiving. QOLLTI-F also has the advantage of being briefer than other carer QOL measures. It contains measures of seven different domains that are determinants of carer QOL, in addition to a summary score. All these measures are valid, reliable and responsive to change in QOL.

What is a good death? Terminally ill patients dealing with normative expectations around death and dying

OBJECTIVE

Developing good care for dying people is important nowadays. Normative expectations about what could be considered as a good death are inextricably bound up with this issue. This article aims to offer an insight in the way terminally ill patients talk about death and dying and how they refer to current western normative expectations about a 'good' death.

METHOD

Thirteen patients with a life expectancy of less than 3 months living at home were interviewed about how they experienced the last phase of their lives. The analysis focused on the way patients tell their personal stories by using normative expectations that are part of a broader cultural western framework.

RESULTS

Five categories of normative expectations were discriminated in the stories of patients: awareness and acceptance, open communication, living one's life till the end, taking care of one's final responsibilities and dealing adequately with emotions.

CONCLUSIONS

The results of this study show that in the search of a good death people show a clear diversity in their way of referring to as well as in dealing with normative expectations that are part of the current cultural paradigm.

PRACTICE IMPLICATIONS

Professional caregivers should be responsive to how a patient deals with and relates to normative expectations about a good death and should support patients in their individual process of dying an 'appropriate death'.

Problems experienced by the informal caregivers of cancer patients and their needs for support

Informal caregivers experience problems of their own for which they need support, but despite the efforts of the World Health Organization to include the well-being of family members and caregivers in the concept of palliative care, their needs are rarely assessed systematically. This report explores caregivers' problems and their needs for professional support. Seventy-six caregivers of cancer patients with advanced disease completed a comprehensive needs assessment questionnaire, the Problems and Needs in Palliative Care questionnaire-caregiver form, listing 67 potential problems in their quality of life and their role of caregiver and 9 items concerning informational needs. The results of this study reveal that the "Top 20" list of the problems and needs reported by caregivers includes fears and emotional burdens; for the most part, caregivers did not need any more professional attention than they were already receiving. Many, however, needed support for managing patients' symptoms and wanted professional attention for the availability and coordination of services. Despite communalities, there was diversity in caregivers' individual needs. Personal needs could be identified with the Problems and Needs in Palliative Care questionnaire-caregiver form checklist. Although only a few caregivers were affected by some issues, such as financial problems, help for them was often needed. In conclusion, most caregivers would like more professional attention for 4 or 5 specific issues, often related to their competence as caregivers for their patients. Using structured needs assessments with the Problems and Needs in Palliative Care questionnaire-caregiver form seems a feasible method to identify the needs of individual caregivers in palliative care.

Relatives in end-of-life care--part 1: a systematic review of the literature the five last years, January 1999-February 2004

AIM

To review systematically research conducted during the past five years focusing on the relatives' situation and needs in end-of-life care.

BACKGROUND AND AIM

That relatives make a large contribution in the care of the dying is well-known. In this situation, relatives often have to solve many new practical problems in the care as well as dealing with the sorrow of both themselves and the dying person. In recent years, palliative care has been developed in many countries and many new studies have been carried out.

METHODS

A systematic search of the literature was performed in the CINAHL and Medline databases. Of the 94 papers analysed, there were 59 qualitative and 35 quantitative studies with differing designs. The studies were carried out in 11 countries and were published in 34 different journals.

RESULTS

The results were categorized in two main themes with several subthemes: (1) being a close relative--the situation: (i) exposed position--new responsibility, (ii) balance between burden and capacity and (iii) positive values; (2) being a close relative--needs: (i) good patient care, (ii) being present, (iii) knowing and communicating and (iv) support from and trusting relationship with the professional. The relative's feelings of security and trust in the professional were found to be of great importance.

CONCLUSION

More than twice as many studies had a descriptive/explorative design, which is of importance in the assessment of evidence. However, different studies complement one another and in summary, it can be said that analytic evidence is unequivocal: good patient care, communication, information and the attitude of the professional are of decisive importance regarding relatives' situation. These results are also in accord with earlier review studies.

RELEVANCE TO CLINICAL PRACTICE

Staff members have a great deal of responsibility for assuring that the patient feels as good as possible, facilitating relatives' involvement based on the family's wishes and limiting the stress and difficulties experienced by the family. The results showed that the relative's satisfaction could depend on the attitude of the professional as well as on good communication, good listening and good information. This can also be viewed as a prerequisite for the professional to get to know the family and to provide 'care in the light'.

Expectations to and evaluation of a palliative home-care team as seen by patients and carers

OBJECTIVES

Although the number of palliative home-care teams is increasing, knowledge of what patients and principal informal carers expect from a home-care team is sparse. We aimed to elucidate this as well as evaluate a home-care team.

PATIENTS AND METHODS

Individual semi-structured interviews with nine patients and six carers before receiving home care and 2-4 weeks after. In total, 26 interviews were conducted. Interviews were analysed with Template Analysis. Peer debriefing was performed.

MAIN RESULTS

Patients and carers expected the team members to have specialised knowledge in palliative care and to improve their sense of security being at home. They also expected respite for carers and activities for patients. They evaluated the team positively but missed respite for carers and 24-h on-call service.

CONCLUSIONS

Patients and carers found the home-care team essential to their sense of security being at home. Primary health care professionals must receive any necessary training outside patients' homes. Offering respite for carers and 24-h on-call service would be an improvement.

Cuidador do idoso com câncer avançado: um ator vulnerado

O câncer é uma doença com altas taxas de prevalência e de mortalidade entre os idosos em nosso meio, com substancial transferência de cuidados deste idoso à família, especialmente nas fases avançadas da doença. Com base na revisão de literatura são enfocados o impacto do câncer na família e a sobrecarga física, psíquica, social e econômica do cuidador familiar do idoso com câncer avançado, além de serem apresentadas algumas propostas de intervenções. Conclui-se pela necessidade de maiores estudos em nosso meio com respeito à sobrecarga do cuidador familiar do idoso com câncer avançado, com a implantação de programas que protejam esse importante ator social.

Resisting vulnerability: the experiences of families who have kin in hospital-a feminist ethnography

Health care restructuring, in an effort to control costs, has resulted in marked organizational change with concomitant influences on nursing practice in the hospital and community contexts. Such changes have resulted in increased levels of acuity among patients and shorter hospital stays. As a consequence, families are being asked to assume greater roles in illness care of family members. At the same time societies and therefore patient populations are becoming increasingly culturally and linguistically diverse. Yet, little is known about hospitalization and help-seeking practices of family caregivers in an ethnoculturally diverse context and the nature of support they require from the health care system. This paper addresses this gap in knowledge. Here we draw upon data gathered in two ethnographic studies of illness care and help-seeking practices in an enthoculturally diverse community. Analysis of family data identified 'resisting vulnerability' as a process central to the families' experiences. This paper examines the process of resisting vulnerability and how it was influenced by the practices of health care professionals and structures of the health system. Implications for practice are discussed.

Cancer caregivers online: hope, emotional roller coaster, and physical/emotional/psychological responses

The demands placed on cancer caregivers are well documented. Support for informal caregivers has been shown to increase hope and decrease psychosocial morbidity. The Internet is a readily available means of support for cancer caregivers, however little research on online support for informal caregivers of cancer patients exists. Descriptive statistics and qualitative analysis were used to evaluate messages posted over a 2-month period on an online cancer caregiver listserv. Three major themes emerged from the data: hope, emotional roller coaster, and physical/emotional/psychological responses. Supportive and hopeful statements prevailed among online participants in the current study. However, subjects also described the emotional roller coaster associated with caregiving. Emotional/physical/psychological responses included anger, weakness, exhaustion, grief, and sadness. Outcome research is needed to help evaluate the efficacy of online support for caregivers. Findings in this study can help nurses focus on some problems common to caregivers of cancer patients and plan appropriate interventions and research.

Time expenditure in patient-related care provided by specialist palliative care nurses in a community hospice service

Although the importance of specialist palliative care in home care programmes for terminally ill patients is well known, German community hospice services did not begin to employ nurses who had specialized in palliative care until the early 1990s. The general tasks of these nurses are sufficiently well defined, but no comprehensive data of their daily workload are available in Germany to date. The present article examines time expenditure in direct patient-related care at the community-based hospice service in Mainz, Germany, by analysing time registration sheets concerning 351 patients who received care from January 2000 until December 2002. Fifty-five per cent of care time spent on each individual patient was in direct contact with that patient and/or his or her relatives, 20% of the time was spent on networking and other related tasks, 17% on travelling and 8% on bereavement counselling. Activities in direct patient contact were allotted to pain and symptom control (36.4%) and psychosocial support of the patient (32.4%) or his or her relatives (27.1%), whereas nursing issues played a minor role (4%).