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Holdsworth R, Rowley G, Farrington E. Caring for dying patients in the community. BMJ 2024; 386:e071661. [PMID: 39117432 DOI: 10.1136/bmj-2022-071661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
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Hashmi SA, Martins RS, Ishtiaq A, Rizvi NA, Mustafa MA, Pervez A, Siddiqui A, Shariq SF, Nadeem S, Haider AH, Waqar MA. Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan. BMC Palliat Care 2024; 23:112. [PMID: 38693518 PMCID: PMC11061908 DOI: 10.1186/s12904-024-01438-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 04/19/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.
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Affiliation(s)
- Syeda Amrah Hashmi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Russell Seth Martins
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Annum Ishtiaq
- Section of Palliative Medicine, Department of Oncology, Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Nashia Ali Rizvi
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Mohsin Ali Mustafa
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Alina Pervez
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Ayra Siddiqui
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | | | - Sarah Nadeem
- Center for Clinical Best Practices, Clinical and Translational Research Incubator (CITRIC), Aga Khan University Hospital, Karachi, 74800, Pakistan
- Section of Endocrinology, Department of Medicine, Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, 74800, Pakistan
| | - Muhammad Atif Waqar
- Section of Palliative Medicine, Department of Oncology, Aga Khan University Hospital, Karachi, 74800, Pakistan.
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Chan RJ, Milch VE, Crawford-Williams F, Agbejule OA, Joseph R, Johal J, Dick N, Wallen MP, Ratcliffe J, Agarwal A, Nekhlyudov L, Tieu M, Al-Momani M, Turnbull S, Sathiaraj R, Keefe D, Hart NH. Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature. CA Cancer J Clin 2023; 73:565-589. [PMID: 37358040 DOI: 10.3322/caac.21788] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 06/27/2023] Open
Abstract
Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.
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Affiliation(s)
- Raymond J Chan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Vivienne E Milch
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Cancer Australia, Sydney, New South Wales, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Fiona Crawford-Williams
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Oluwaseyifunmi Andi Agbejule
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Ria Joseph
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Jolyn Johal
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Narayanee Dick
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Matthew P Wallen
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Institute of Health and Wellbeing, Federation University Australia, Ballarat, Victoria, Australia
| | - Julie Ratcliffe
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Anupriya Agarwal
- Cancer Australia, Sydney, New South Wales, Australia
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Larissa Nekhlyudov
- Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Tieu
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | | | | | | | - Dorothy Keefe
- Cancer Australia, Sydney, New South Wales, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Nicolas H Hart
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Cancer and Palliative Care Outcomes Centre, School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
- Institute for Health Research, The University of Notre Dame Australia, Perth, Western Australia, Australia
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia
- Human Performance Research Centre, Innovative Solutions for Well-being and Health (INSIGHT) Research Institute, Faculty of Health, University of Technology Sydney (UTS), Sydney, New South Wales, Australia
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Rawlings D, Damarell R, Tait P, Chakraborty A, Dalli A, Devery K, Tieman J. Emerging health and social policy considerations for safe and quality end-of-life care in Australia - the evidence, gaps and challenges. AUST HEALTH REV 2023; 47:586-588. [PMID: 37696753 DOI: 10.1071/ah23166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
Recognition of the importance of end-of-life care will enable improvements in the quality of care delivered to patients and their families. Australia is experiencing an increasing number of deaths, (many expected), with an aging population who are living longer, often with multimorbidity. This makes end of life care a priority. The last year of someone's life takes place in a complex healthcare system, with increasing pressures on care delivery, placing the spotlight on health service providers to ensure that teams and individuals are supported and enabled to provide such care. Two rapid literature reviews identified best practice principles and processes for delivering safe and high-quality end-of-life care in acute care, aged care and community settings. The reviews identified that end-of-life care is experienced within the whole health and social care system, including hospital admissions interspersed with care in the community, outpatient and emergency department visits and potentially admission to a hospice. Much of this last year of life is spent at home, which may be a personal residence, an aged care facility, prison, supported accommodation or even on the streets. Transitions across settings requires seamless care, as well as organisational readiness to deliver safe and culturally appropriate care. This is more important now with end-of-life care subject to quality assurance mechanisms within the National Safety and Quality Health Service Standards (2nd edn): Comprehensive care. This requires all sectors to work collaboratively when caring for someone at the end of their life in order to see positive changes in care outcomes.
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Affiliation(s)
- Deb Rawlings
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
| | - Raechel Damarell
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
| | - Paul Tait
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
| | - Amal Chakraborty
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia; and
| | - Angie Dalli
- Australian Commission on Safety and Quality in Health Care, Level 5, 255 Elizabeth Street, Sydney, NSW 2000, Australia
| | - Kim Devery
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
| | - Jennifer Tieman
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia
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Qureshi SP, Jones D, Dewar A. Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature. QUALITATIVE HEALTH RESEARCH 2022; 32:1881-1896. [PMID: 35981561 PMCID: PMC9511242 DOI: 10.1177/10497323221119939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.
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Affiliation(s)
- Shaun Peter Qureshi
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Derek Jones
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Avril Dewar
- Edinburgh Medical School, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
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Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev 2022; 7:CD013116. [PMID: 35802350 PMCID: PMC9266997 DOI: 10.1002/14651858.cd013116.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
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Affiliation(s)
- Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Natalie K Bradford
- Centre for Children's Health Research, Cancer and Palliative Care Outcomes at Centre for Children's Health Research, Queensland University of Technology (QUT), South Brisbane, Australia
| | - Simon Henderson
- Department of Aviation, The University of New South Wales, Sydney, Australia
| | - Anthony Herbert
- Paediatric Palliative Care Service, Children's Health Queensland, Hospital and Health Service, South Brisbane, Australia
- Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| | | | - Amanda Henderson
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
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Silvia T, Gianfranco M, Cristina A, Sara A, Carlo P, Giovanna A. Consultations’ demand for a hospital palliative care unit: how to increase appropriateness? Implementing and evaluating a multicomponent educational intervention aimed at increase palliative care complexity perception skill. BMC Palliat Care 2022; 21:90. [PMID: 35619110 PMCID: PMC9133822 DOI: 10.1186/s12904-022-00968-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/04/2022] [Indexed: 02/06/2023] Open
Abstract
Background Planned, multidisciplinary teams’ discussions of cases are common in cancer care, but their impact on patients’ outcome is not always clear. Palliative care (PC) needs might emerge long before the last weeks of life. Many palliative care patients could be managed from the usual care staff, if appropriately trained; specialist palliative care should be provided to patients with more complex needs. Staff needs adequate training, so that only patients presenting a higher complexity are properly referred to the second level (“specialized”) PC services. In the considered hospital setting, “tumour boards” (multidisciplinary discussions) refer often to a low number of patients. Overall complexity of patients’ needs is hardly considered. Methods A mixed method pilot study with data triangulation of professionals’ interviews and an independently structured evaluation of complexity of referred patients, before and after the intervention, using the PALCOM instrument. We trained four teams of professionals to deliver first-level palliation and to refer patients with complex needs detected in multidisciplinary discussions. A multicomponent, first level PC educational intervention, including information technology’s adaptation, a training course, and bedside training was offered from the specialized PC Services, to all the HPs involved in multidisciplinary pancreas, lung, ovarian, and liver tumour boards. Results While the level of complexity of referred patients did not increase, trainees seemed to develop a better understanding of palliative care and a higher sensitivity to palliative needs. The number of referred patients increased, but patients’ complexity did not. Qualitative data showed that professionals seemed to be more aware of the complexity of PC needs. A “meaning shift” was perceived, specifically on the referral process (e.g., “when” and “for what” referring to specialist PC) and on the teams’ increased focus on patients’ needs. The training, positively received, was adapted to trainees’ needs and observations that led also to organizational modifications. Conclusions Our multicomponent intervention positively impacted the number of referrals but not the patients’ complexity (measured with the PALCOM instrument). Hospital staff does not easily recognize that patients may have PC needs significantly earlier than at the end of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00968-7.
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Gartner JB, Abasse KS, Bergeron F, Landa P, Lemaire C, Côté A. Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review. BMC Health Serv Res 2022; 22:558. [PMID: 35473632 PMCID: PMC9040248 DOI: 10.1186/s12913-022-07960-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Confusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework. METHODS An innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed. RESULTS Forty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management. CONCLUSIONS This study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.
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Affiliation(s)
- Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada.
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada.
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada.
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada.
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada.
| | - Kassim Said Abasse
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
| | - Frédéric Bergeron
- Bibliothèque-Direction des services-conseils, Université Laval, Québec, QC, Canada
| | - Paolo Landa
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Département d'opérations et systèmes de décision, Université Laval, Québec, QC, Canada
| | - Célia Lemaire
- Université de Strasbourg, EM Strasbourg-Business School, HuManiS, Strasbourg, France
| | - André Côté
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
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Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway. Oncol Ther 2021; 9:671-693. [PMID: 34731447 PMCID: PMC8593089 DOI: 10.1007/s40487-021-00176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/19/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region. METHODS A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively. RESULTS To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR. CONCLUSION An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.
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Walsh SC, Murphy E, Devane D, Sampson EL, Connolly S, Carney P, O'Shea E. Palliative care interventions in advanced dementia. Cochrane Database Syst Rev 2021; 9:CD011513. [PMID: 34582034 PMCID: PMC8478014 DOI: 10.1002/14651858.cd011513.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dementia is a chronic, progressive and ultimately fatal neurodegenerative disease. Advanced dementia is characterised by profound cognitive impairment, inability to communicate verbally and complete functional dependence. Usual care of people with advanced dementia is not underpinned universally by a palliative approach. Palliative care has focused traditionally on care of people with cancer, but for more than a decade, there have been calls worldwide to extend palliative care services to include all people with life-limiting illnesses in need of specialist care, including people with dementia. This review is an updated version of a review first published in 2016. OBJECTIVES To assess the effect of palliative care interventions in advanced dementia. SEARCH METHODS We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's Specialised Register on 7 October 2020. ALOIS contains records of clinical trials identified from monthly searches of several major healthcare databases, trial registries and grey literature sources. We ran additional searches across MEDLINE (OvidSP), Embase (OvidSP), four other databases and two trial registries on 7 October 2020 to ensure that the searches were as comprehensive and as up-to-date as possible. SELECTION CRITERIA We searched for randomised (RCTs) and non-randomised controlled trials (nRCTs), controlled before-and-after studies and interrupted time series studies evaluating the impact of palliative care interventions for adults with advanced dementia of any type. Participants could be people with advanced dementia, their family members, clinicians or paid care staff. We included clinical interventions and non-clinical interventions. Comparators were usual care or another palliative care intervention. We did not exclude studies based on outcomes measured. DATA COLLECTION AND ANALYSIS At least two review authors (SW, EM, PC) independently assessed all potential studies identified in the search against the review inclusion criteria. Two authors independently extracted data from eligible studies. Where appropriate, we estimated pooled treatment effects in a fixed-effect meta-analysis. We assessed the risk of bias of included studies using the Cochrane Risk of Bias tool and the overall certainty of the evidence for each outcome using GRADE. MAIN RESULTS Nine studies (2122 participants) met the review inclusion criteria. Two studies were individually-randomised RCTs, six were cluster-randomised RCTs and one was a controlled before-and-after study. We conducted two separate comparisons: organisation and delivery of care interventions versus usual care (six studies, 1162 participants) and advance care planning interventions versus usual care (three studies, 960 participants). Two studies were carried out in acute hospitals and seven in nursing homes or long-term care facilities. For both comparisons, we found the included studies to be sufficiently similar to conduct meta-analyses. Changes to the organisation and delivery of care for people with advanced dementia may increase comfort in dying (MD 1.49, 95% CI 0.34 to 2.64; 5 studies, 335 participants; very low certainty evidence). However, the evidence is very uncertain and unlikely to be clinically significant. These changes may also increase the likelihood of having a palliative care plan in place (RR 5.84, 95% CI 1.37 to 25.02; 1 study, 99 participants; I2 = 0%; very low certainty evidence), but again the evidence is very uncertain. Such interventions probably have little effect on the use of non-palliative interventions (RR 1.11, 95% CI 0.71 to 1.72; 2 studies, 292 participants; I2 = 0%; moderate certainty evidence). They may also have little or no effect on documentation of advance directives (RR 1.46, 95% CI 0.50 to 4.25; 2 studies, 112 participants; I2 = 52%; very low certainty evidence), or whether discussions take place about advance care planning (RR 1.08, 95% CI 1.00 to 1.18; 1 study, 193 participants; I2 = 0%; very low certainty evidence) and goals of care (RR 2.36, 95% CI 1.00 to 5.54; 1 study, 13 participants; I2 = 0%; low certainty evidence). No included studies assessed adverse effects. Advance care planning interventions for people with advanced dementia probably increase the documentation of advance directives (RR 1.23, 95% CI 1.07 to 1.41; 2 studies, 384; moderate certainty evidence) and the number of discussions about goals of care (RR 1.33, 95% CI 1.11 to 1.59; 2 studies, 384 participants; moderate certainty evidence). They may also slightly increase concordance with goals of care (RR 1.39, 95% CI 1.08 to 1.79; 1 study, 63 participants; low certainty evidence). On the other hand, they may have little or no effect on perceived symptom management (MD -1.80, 95% CI -6.49 to 2.89; 1 study, 67 participants; very low certainty evidence) or whether advance care planning discussions occur (RR 1.04, 95% CI 0.87 to 1.24; 1 study, 67 participants; low certainty evidence). AUTHORS' CONCLUSIONS The evidence on palliative care interventions in advanced dementia is limited in quantity and certainty. When compared to usual care, changes to the organisation and delivery of care for people with advanced dementia may lead to improvements in comfort in dying, but the evidence for this was of very low certainty. Advance care planning interventions, compared to usual care, probably increase the documentation of advance directives and the occurrence of discussions about goals of care, and may also increase concordance with goals of care. We did not detect other effects. The uncertainty in the evidence across all outcomes in both comparisons is mainly driven by imprecision of effect estimates and risk of bias in the included studies.
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Affiliation(s)
- Sharon C Walsh
- Economics, National University of Ireland Galway, Galway, Ireland
| | - Edel Murphy
- PPI Ignite Programme, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Patricia Carney
- Department of Public Health HSE Midlands, Health Service Executive, Tullamore, Ireland
| | - Eamon O'Shea
- School of Business and Economics, National University of Ireland Galway, Galway, Ireland
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AKDENİZ KUDUBEŞ A, AYAR D, BEKTAŞ İ, BEKTAŞ M. EFFECTIVENESS OF PEDIATRIC PALLIATIVE CARE EDUCATION PROGRAM IN STRENGTHENING NURSING STUDENTS’ PALLIATIVE CARE PRACTICES AND ATTITUDES TOWARD CARE OF THE DYING. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2021. [DOI: 10.33808/clinexphealthsci.836362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Welch V, Mathew CM, Babelmorad P, Li Y, Ghogomu ET, Borg J, Conde M, Kristjansson E, Lyddiatt A, Marcus S, Nickerson JW, Pottie K, Rogers M, Sadana R, Saran A, Shea B, Sheehy L, Sveistrup H, Tanuseputro P, Thompson‐Coon J, Walker P, Zhang W, Howe TE. Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1175. [PMID: 37051456 PMCID: PMC8988637 DOI: 10.1002/cl2.1175] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Background By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value. Objectives This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence. Search Methods We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov). Selection Criteria Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps. Data Collection and Analysis We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist. Main Results After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues. Authors' Conclusions There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.
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Affiliation(s)
- Vivian Welch
- Methods CentreBruyère Research InstituteOttawaCanada
| | | | | | - Yanfei Li
- Evidence‐Based Social Science Research Center, School of Public HealthLanzhou UniversityLanzhouChina
| | | | | | - Monserrat Conde
- Cochrane Campbell Global Ageing Partnership FieldFaroPortugal
| | | | | | - Sue Marcus
- Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | | | | | - Morwenna Rogers
- NIHR ARC, South West Peninsula (PenARC)University of Exeter Medical SchoolExeterUK
| | | | | | - Beverly Shea
- Bruyère Research InstituteUniversity of OttawaOttawaCanada
| | - Lisa Sheehy
- Bruyère Research InstituteUniversity of OttawaOttawaCanada
| | - Heidi Sveistrup
- Bruyère Research InstituteUniversity of OttawaOttawaCanada
- Faculty of Health SciencesUniversity of OttawaOttawaCanada
| | | | - Joanna Thompson‐Coon
- NIHR ARC South West Peninsula (PenARC)University of Exeter Medical SchoolExeterUK
| | - Peter Walker
- Faculty of MedicineUniversity of OttawaOttawaCanada
| | - Wei Zhang
- Access to Medicines, Vaccines and Health ProductsWorld Health OrganizationGenevaSwitzerland
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Sagara Y, Mori M, Yamamoto S, Eguchi K, Iwatani T, Naito Y, Kogawa T, Tanaka K, Kotani H, Yasojima H, Ozaki Y, Noguchi E, Miyasita M, Kondo N, Niikura N, Toi M, Shien T, Iwata H. Current Status of Advance Care Planning and End-of-life Communication for Patients with Advanced and Metastatic Breast Cancer. Oncologist 2021; 26:e686-e693. [PMID: 33321004 PMCID: PMC8018302 DOI: 10.1002/onco.13640] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 12/07/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a process that supports adults in understanding and sharing their personal values, life goals, and preferences regarding future medical care. We examined the current status of ACP and end-of-life (EOL) communication between oncologists and patients with metastatic breast cancer. MATERIALS AND METHODS We conducted a survey among 41 institutions that specialize in oncology by using an online tool in October 2019. Participants (118 physicians) from 38 institutions completed a 39-item questionnaire that measured facility type and function; physicians' background and clinical approach, education about EOL communication, and understanding about ACP; and the current situation of ACP and EOL discussions. RESULTS Ninety-eight responses concerning physicians' engagement in ACP with patients were obtained. Seventy-one (72%) answered that they had engaged in ACP. Among these, 23 (33%) physicians used a structured format to facilitate the conversation in their institutions, and only 6 (8%) settled triggers or sentinel events for the initiation of ACP. In the multivariable analysis, only the opportunity to learn communication skills was associated with physicians' engagement with ACP (odds ratio: 2.8, 95% confidence interval: 1.1-7.0). The frequency and timing of communication about ACP and EOL care with patients substantially varied among the oncologists. Communication about patients' life expectancy was less frequent compared with other topics. CONCLUSION The opportunity to improve EOL communication skills promoted physicians' engagement with ACP among patients with metastatic/advanced breast cancer. However, there were still substantial variabilities in the method, frequency, and timing of ACP and EOL communication among the oncologists. IMPLICATIONS FOR PRACTICE This study found that the opportunity to improve end-of-life (EOL) communication skills promoted physicians' engagement in advance care planning (ACP) among patients with metastatic/advanced breast cancer. All oncologists who treat said patients are encouraged to participate in effective education programs concerning EOL communication skills. In clinical practice, there are substantial variabilities in the method, frequency, and timing of ACP and EOL communication among oncologists. As recommended in several clinical guidelines, the authors suggest a system that identifies patients who require conversations about their care goals, a structured format to facilitate the conversations, and continuous measurement for improving EOL care and treatment.
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Affiliation(s)
- Yasuaki Sagara
- Department of Breast Surgery, Tokai University School of Medicine, Kanagawa, Japan.,Department of Breast Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Breast Surgical Oncology, Social Medical Corporation Hakuaikai, Sagara Hospital, Kagoshima, Japan
| | - Masanori Mori
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Sena Yamamoto
- Division of Health Sciences, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiko Eguchi
- Department of Nursing, Social Medical Corporation Hakuaikai, Sagara Hospital, Kagoshima, Japan
| | - Tsuguo Iwatani
- Department of Breast Surgery, Experimental Therapeutics, and Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoichi Naito
- Department of General Internal Medicine, Experimental Therapeutics, and Breast and Medical Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takahiro Kogawa
- Division of Early Clinical Development for Cancer, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyo Tanaka
- Department of Breast and Endocrine Surgery, Toranomon Hospital, Tokyo, Japan
| | - Haruru Kotani
- Department of Breast Oncology, Aichi Cancer Center, Nagoya, Japan
| | - Hiroyuki Yasojima
- Department of Surgery, Breast Oncology, Osaka National Hospital, Osaka, Japan
| | - Yukinori Ozaki
- Department of Medical Oncology, Toranomon Hospital, Tokyo, Japan
| | - Emi Noguchi
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Miyasita
- Department of Breast and Endocrine Surgical Oncology, Tohoku University, Sendai, Japan
| | - Naoto Kondo
- Department of Breast Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Naoki Niikura
- Department of Breast Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Masakazu Toi
- Department of Breast Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tadahiko Shien
- Department of Breast and Endocrine Surgery, Okayama University, Okayama, Japan
| | - Hiroji Iwata
- Department of Breast Oncology, Aichi Cancer Center, Nagoya, Japan
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14
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Klapwijk MS, Dekker NL, Caljouw MAA, Achterberg WP, van der Steen JT. Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians' and nurse practitioners' perceptions. BMC Palliat Care 2020; 19:183. [PMID: 33256717 PMCID: PMC7706263 DOI: 10.1186/s12904-020-00686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 11/18/2020] [Indexed: 08/29/2023] Open
Abstract
Background The Liverpool care pathway for the dying patient (LCP) is a multidisciplinary tool developed for the dying phase for use in palliative care settings. The literature reports divergent experiences with its application in a nursing home setting related to its implementation and staff competencies. The aim of this study is to understand how the LCP is being used in the context of the nursing home, including for residents with dementia, and experienced from the perspectives of those responsible for medical treatment in nursing homes. Methods A mixed-methods approach was used, consisting of a survey followed by interviews. A link to a 9-item online survey with closed and open-ended questions was emailed to all physicians and nurse practitioners of 33 care organisations with nursing homes in three regions of the Netherlands (North, West and South). In addition, 10 respondents with particularly positive or negative experiences were selected for semi-structured interviews. Results The survey was completed by 159 physicians and nurse practitioners. The respondents were very positive on the content and less positive on the use of the LCP, although they reported difficulties identifying the right time to start the LCP, especially in case of dementia. Also using the LCP was more complicated after the implementation of the electronic health record. The LCP was judged to be a marker of quality for the assessment of symptoms in the dying phase and communication with relatives. Conclusion An instrument that prompts regular assessment of a dying person was perceived by those responsible for (medical) care to contribute to good care. As such, the LCP was valued, but there was a clear need to start it earlier than in the last days or hours of life, a need for a shorter version, and for integration of the LCP in the electronic health record. Regular assessments with an instrument that focusses on quality of care and good symptom control can improve palliative care for nursing home residents with and without dementia.
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Affiliation(s)
- Maartje S Klapwijk
- Department of Public Health and Primary Care, Leiden University Medical Center, P.O. Box 9600, Leiden, 2300 RC, the Netherlands. .,Marente, Leiden, the Netherlands.
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, the Netherlands
| | - Monique A A Caljouw
- Department of Public Health and Primary Care, Leiden University Medical Center, P.O. Box 9600, Leiden, 2300 RC, the Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, P.O. Box 9600, Leiden, 2300 RC, the Netherlands
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, P.O. Box 9600, Leiden, 2300 RC, the Netherlands
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Lasmarías C, Guanter L, Turrillas P, Peñafiel J, Gómez-Batiste X. Evaluating the impact of a multidisciplinary master programme in palliative care on professional learning outcomes: a cross-sectional study after 20 years of experience. BMJ Support Palliat Care 2020:bmjspcare-2020-002528. [PMID: 32994188 DOI: 10.1136/bmjspcare-2020-002528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the impact after 20 years of a Master's degree in palliative care (MsPC) on the participants' educational outcomes in terms of educational needs satisfaction, motivation, applicability and professional development (PD) in the palliative care (PC) field. METHODS A cross-sectional study was conducted between October 2016 and February 2017. Participants were students of the MsPC from 13 editions. An ad hoc survey comprising closed-end questions was provided. Variables such as sociodemographic and learning outcomes, based on Kirkpatrick's model, were included. RESULTS Respondents were 76.6% women, and 60% were between 30 and 50 years of age. Over half of participants were physicians (57.4%), with >15 years of experience (52%). 77% (n=152) reported previous work experience (PWE) in PC, and 23% (n=45) had no PWE. After completing the MsPC, 49% of those without PWE were hired to work in a PC unit, while 84,2% with PWE continued work in a PC-related position. 51.6% professionals with PWE were currently working in other PC areas, such as training or research. High scores were observed on expectations, training needs, motivation in professional practice, PD, applicability and satisfaction, in both groups. Data have shown statistically significant differences on the perceived value of the MsPC to obtain work in the PC field (p=0.006). CONCLUSIONS This MsPC training programme improves educational outcomes, and promotes PD, regardless of PWE in PC. Interdisciplinary training for all professionals who care for PC individuals is required. To ensure the quality of education in PC programmes, a systematic process of continuous evaluation is needed.
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Affiliation(s)
- Cristina Lasmarías
- Education and Training, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Catalunya, Spain
- Catalonia Chronic Care Research Group, Universitat de Vic-Universitat Central de Catalunya, Vic, Catalunya, Spain
| | - Lourdes Guanter
- Education and Training, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Catalunya, Spain
| | - Pamela Turrillas
- Chair of Palliative Care, Universitat de Vic-Universitat Central de Catalunya, Vic, Catalunya, Spain
- The 'Qualy' Observatory, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Catalunya, Spain
| | - Judith Peñafiel
- Department of Statistics, Biomedical Research Institute of Bellvitge, IDIBELL, Barcelona, Spain
| | - Xavier Gómez-Batiste
- Catalonia Chronic Care Research Group, Universitat de Vic-Universitat Central de Catalunya, Vic, Catalunya, Spain
- Chair of Palliative Care, Universitat de Vic-Universitat Central de Catalunya, Vic, Catalunya, Spain
- The 'Qualy' Observatory, Catalan Institute of Oncology, L'Hospitalet de Llobregat, Catalunya, Spain
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Omidi K, Dehghan M, Shahrbabaki PM. Effectiveness of A Traditional Training Method in Increasing Long-Term End-of-Life Care Perception and Clinical Competency among Oncology Nurses: A Pilot Clinical Trial. Asia Pac J Oncol Nurs 2020; 7:287-294. [PMID: 32642501 PMCID: PMC7325772 DOI: 10.4103/apjon.apjon_15_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/17/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Patients with cancer face numerous problems at the end of their lives, which makes palliative care necessary for a peaceful death. Considering the important role nurses play in the provision of end-of-life care, the present study was conducted to study the effect of a traditional training method on nurses' perception of and clinical competency in providing end-of-life care to patients with cancer in a hospital in Southeastern Iran. METHODS This was a pilot clinical trial in which the nurses in an oncology ward were allocated to two groups, experimental (n = 24) and control (n = 33), using a table of random numbers. The experiment group received three sessions of workshop training. The nurses' perception and clinical competency were measured before and 3 months postintervention. RESULTS The results showed the perception scores in the experimental and control groups to be 171.75 ± 19.54 and 170.03 ± 17.03 before education and 176.16 ± 19.54 and 176.12 ± 16.12 postintervention, respectively. The scores of clinical competency were 98.71 ± 10.24 and 99.58 ± 12.17 before education and 101.5 ± 14.67 and 104.97 ± 12 postintervention in the experimental and control groups, respectively. According to the findings, neither of the groups showed a significant difference between pre- and post-intervention in terms of perception of or clinical competency in end-of-life care. CONCLUSIONS A traditional training method such as workshop training cannot cause long-term improvement in nurses' end-of-life care perception or clinical competency. It seems that nurses would benefit from acquiring cognitive and behavioral skills and knowledge through a more continuous form of instruction delivered through modern blended educational methods.
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Affiliation(s)
- Khaled Omidi
- School of Nursing and Midwifery, Iranshahr University of Medical Sciences, Iranshahr, Iran
| | - Mahlagha Dehghan
- Nursing Research Center, Razi School of Nursing and Midwifery, Department of Critical Care Nursing, Kerman University of Medical Sciences, Kerman, Iran
| | - Parvin Mangolian Shahrbabaki
- Nursing Research Center, Razi School of Nursing and Midwifery, Department of Critical Care Nursing, Kerman University of Medical Sciences, Kerman, Iran
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17
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[The role of the family doctor in the palliative care of chronic and terminally ill patients]. Semergen 2019; 45:349-355. [PMID: 30718073 DOI: 10.1016/j.semerg.2018.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/28/2018] [Accepted: 09/24/2018] [Indexed: 12/19/2022]
Abstract
The objective of this work was to identify the role of family physicians in the care of patients and their families in the approach to the end of life. Nowadays, with the increase in the demand for care of patients with terminal illnesses, there is also evidence on the lack of physicians with the profile and skills to fulfil this coverage deficit. A review of the literature was carried out in five databases from January 2015 to May 2018, and concluded that family doctors, based on their professional skills, ability to engage with the patients, their families, and their performance in the coordination of medical resources, are in an ideal position to attend and solve complex problems of patients at the end of life. In the present review, the specific roles of family physicians in clinical and psychosocial areas, and also the difficulties in facing the challenges in the care of patients and families undergoing the end of life process are described.
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Walther F, Kuester D, Schmitt J. Impact of Complex Quality-Interventions on Patient Outcome: A Systematic Overview of Systematic Reviews. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2019; 56:46958019884182. [PMID: 31746255 PMCID: PMC6868575 DOI: 10.1177/0046958019884182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/23/2019] [Accepted: 09/27/2019] [Indexed: 01/08/2023]
Abstract
Quality of care and the increasing strategies to its promotion, especially in inpatient settings, led to the question which quality-interventions work best and which do not. The aim was to summarize and critically appraise the evidence on the effects of structure- and/or process-related quality-interventions on patient outcome in predominantly controlled and inpatient settings. A systematic overview of systematic reviews after electronic searches in Medline, Embase, Cinahl, and PsycINFO, supplemented by hand search and expert survey, was conducted. From a total of 1559 identified records, 37 reviews fulfilled the inclusion criteria. 26 reviews assessed process-related quality-interventions, 6 structure-related quality-interventions, and 5 combined structure- and process-related quality-interventions. In all, 19 reviews reported pooled effect estimates (meta-analysis). Based on the evidence of this systematic overview, stroke units and pathways can be recommended. Although patient-relevant improvements for interprofessional approaches and discharge planning have been reported, pooled effect estimated evidence are currently missing for these and other quality-interventions.
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Affiliation(s)
- Felix Walther
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Denise Kuester
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
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Bloomer MJ, Botti M, Runacres F, Poon P, Barnfield J, Hutchinson AM. Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study. Palliat Med 2018; 32:1615-1623. [PMID: 30074431 PMCID: PMC6238176 DOI: 10.1177/0269216318790353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND In geriatric inpatient rehabilitation settings, where the goal is to optimise function, providing end-of-life care can be challenging. AIM The aim of this study is to explore how end-of-life care goals and decision-making are communicated in a geriatric inpatient rehabilitation setting. DESIGN The design is a qualitative descriptive design using semi-structured individual and group interviews. SETTING/PARTICIPANTS This study was conducted in a 154-bed facility in metropolitan Melbourne, Australia, providing geriatric inpatient rehabilitation for older patients; medical, nursing and allied health clinicians, who had cared for an inpatient who died, were recruited. DATA COLLECTION Participants were interviewed using a conversational approach, guided by an 'aide memoire'. RESULTS A total of 19 clinicians participated in this study, with 12 interviewed individually and the remaining 7 clinicians participating in group interviews. The typical patient was described as older, frail and with complex needs. Clinicians described the challenge of identifying patients who were deteriorating towards death, with some relying on others to inform them. How patient deterioration and decision-making was communicated among the team varied. Communication with the patient/family about dying was expected but did not always occur, nor was it always documented. Some clinicians relied on documentation, such as commencement of a dying care pathway to indicate when a patient was dying. CONCLUSION Clinicians reported difficulties recognising patient deterioration towards death. Uncertainty and inconsistent communication among clinicians about patient deterioration negatively impacted team understanding, decision-making, and patient and family communication. Further education for all members of the multidisciplinary team focusing on how to recognise and communicate impending death will aid multidisciplinary teams to provide quality end-of-life care when required.
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Affiliation(s)
- Melissa J Bloomer
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
| | - Mari Botti
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,3 Epworth/Deakin Centre for Clinical Nursing Research, Richmond, VIC, Australia
| | - Fiona Runacres
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,7 Department of Palliative Care, Calvary Health Care Bethlehem, South Caulfield, VIC, Australia.,8 The University of Notre Dame, Darlinghurst, NSW, Australia
| | - Peter Poon
- 5 Supportive and Palliative Care Unit, Monash Health, Clayton, VIC, Australia.,6 School of Medicine, Monash University, Clayton, VIC, Australia.,9 Eastern Palliative Care Association, Melbourne, VIC, Australia
| | - Jakqui Barnfield
- 10 Rehabilitation, Aged Persons Mental Health and Residential Services, Clayton, VIC, Australia.,11 School of Nursing and Midwifery, Monash University, Clayton, VIC, Australia
| | - Alison M Hutchinson
- 1 Deakin University, Burwood, VIC, Australia.,2 Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC, Australia.,4 Centre for Nursing Research, Deakin University and Monash Health Partnership, Monash Health, Clayton, VIC, Australia
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Lyon ME, Garvie PA, D'Angelo LJ, Dallas RH, Briggs L, Flynn PM, Garcia A, Cheng YI, Wang J. Advance Care Planning and HIV Symptoms in Adolescence. Pediatrics 2018; 142:e20173869. [PMID: 30341154 PMCID: PMC6317555 DOI: 10.1542/peds.2017-3869] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To determine the effect of family-centered pediatric advance care planning (FACE pACP) on HIV-specific symptoms. METHODS In this single-blinded, randomized controlled trial conducted at 6 US hospital-based HIV clinics, 105 adolescent-family dyads, randomly assigned from July 2011 to June 2014, received 3 weekly sessions in either the FACE pACP arm ([1] pediatric advance care planning survey, [2] Respecting Choices interview, and [3] 5 Wishes directive) or the control arm ([1] developmental history, [2] safety tips, and [3] nutrition and exercise tips). The General Health Assessment for Children measured patient-reported HIV-specific symptoms. Latent class analyses clustered individual patients based on symptom patterns. Path analysis examined the mediating role of dyadic treatment congruence with respect to the intervention effect on symptom patterns. RESULTS Patients were a mean age of 17.8 years old, 54% male, and 93% African American. Latent class analysis identified 2 latent HIV-symptom classes at 12 months: higher symptoms and suffering (27%) and lower symptoms and suffering (73%). FACE pACP had a positive effect on dyadic treatment congruence (β = .65; 95% CI: 0.04 to 1.28), and higher treatment congruence had a negative effect on symptoms and suffering (β = -1.14; 95% CI: -2.55 to -0.24). Therefore, FACE pACP decreased the likelihood of symptoms and suffering through better dyadic treatment congruence (β = -.69; 95% CI: -2.14 to -0.006). Higher religiousness (β = 2.19; 95% CI: 0.22 to 4.70) predicted symptoms and suffering. CONCLUSIONS FACE pACP increased and maintained agreement about goals of care longitudinally, which lowered adolescents' physical symptoms and suffering, suggesting that early pACP is worthwhile.
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Affiliation(s)
- Maureen E Lyon
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Patricia A Garvie
- Research Department, Children's Diagnostic and Treatment Center, Fort Lauderdale, Florida
| | - Lawrence J D'Angelo
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Linda Briggs
- Respecting Choices, Coalition to Transform Advanced Care Innovations, Washington, District of Columbia; and
| | - Patricia M Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ana Garcia
- Department of Pediatrics, Division of Infectious Disease and Immunology, Batchelor Children's Research Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Yao I Cheng
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
| | - Jichuan Wang
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
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21
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Henderson A, Ryan R, Henderson S, Young J, Bradford NK, Bothroyd JI, Herbert A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Hippokratia 2018. [DOI: 10.1002/14651858.cd013116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Amanda Henderson
- University of the Sunshine Coast; School of Nursing, Midwifery and Paramedicine; Sippy Downs Queensland Australia 4556
| | - Rebecca Ryan
- La Trobe University; Centre for Health Communication and Participation, School of Psychology and Public Health; Bundoora VIC Australia 3086
| | - Simon Henderson
- The University of New South Wales; Department of Aviation; Sydney NSW Australia 2052
| | - Jeanine Young
- University of the Sunshine Coast; School of Nursing, Midwifery and Paramedicine; Sippy Downs Queensland Australia 4556
| | - Natalie K Bradford
- The University of Queensland; The Centre for Online Health, School of Medicine; Lady Cilento Children's Hospital Brisbane Australia 4012
| | - Josephine I Bothroyd
- Health Care Consumers’ Association of the ACT; Self-employed; 49 Burrendong Street Duffy ACT Australia 2611
| | - Anthony Herbert
- Lady Cilento Children's Hospital; Paediatric Palliative Care; 501 Stanley Street South Brisbane Queensland Australia 4101
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22
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Development and Validity of the Nursing Care Scale and Nurse's Difficulty Scale in Caring for Dying Patients With Cancer and Their Families in General Hospitals in Japan. J Hosp Palliat Nurs 2018; 21:174-182. [PMID: 30063557 PMCID: PMC6400446 DOI: 10.1097/njh.0000000000000482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study develops and examines the validity and reliability of 2 scales, respectively, for evaluating nursing care and the experience of difficulties providing nursing care for dying patients with cancer and their families. A cross-sectional anonymous questionnaire was administered to nursing staff caring for dying patients with cancer and their families in 4 general hospitals and a university hospital in Japan. The instruments assessed were the Nursing Care Scale for Dying Patients and Their Families (NCD) and the Nurse’s Difficulty Scale for Dying Patients and Their Families (NDD). Of the 497 questionnaires sent to nurses, 401 responses (80%) were analyzed. Factor analyses revealed that the NCD and NDD consisted of 12 items with 4 subscales: “symptom management,” “reassessment of current treatment and nursing care,” “explanation to family,” and “respect for the patient and family’s dignity before and after death.” These scales had sufficient convergent and discriminative validity, sufficient internal consistency (α of subscales: NCD, 0.71-0.87; NDD, 0.74-0.93), and sufficient test-retest reliability (intraclass correlation coefficient of subscales: NCD, 0.59-0.81; NDD, 0.67-0.82) to be used as self-assessments and evaluation tools in education programs to improve the quality of nursing care for the dying patients and their families.
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 02/02/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the 'boundary object' concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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24
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 01/29/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('the LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review. The ensuing debate among clinicians polarised between 'blaming' of the LCP and regret at its removal. Employing the concept of 'boundary objects', we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP 'scandal' demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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Redman M, Pearce J, Gajebasia S, Johnson M, Finn G. Care of the dying: a qualitative exploration of Foundation Year doctors' experiences. MEDICAL EDUCATION 2017; 51:1025-1036. [PMID: 28744956 DOI: 10.1111/medu.13358] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 11/21/2016] [Accepted: 04/18/2017] [Indexed: 05/26/2023]
Abstract
CONTEXT Foundation Year doctors (FYs), who are newly qualified, are expected to provide care for dying patients. Experiences at this early mandatory stage of training may form the foundation for future encounters, but little is documented about what these experiences involve. The aim of this research was to explore the experiences of FYs in caring for the dying, using the recently published Priorities for Care of the Dying Person as a conceptual framework, to identify areas for improvement in education and clinical practice. METHODS Semi-structured group and individual interviews were conducted to explore the experiences of FYs and how these relate to the five aspects of Priorities for Care of the Dying Person: 'recognise', 'communicate', 'involve', 'support' and 'plan and do'. All FYs in the North Yorkshire and East Coast Foundation School (n=335) were invited to participate and 47 FYs were recruited from five sites through convenience sampling and snowballing. Recordings were transcribed verbatim and a framework analysis approach was used with the published Priorities for Care of the Dying Person guidelines as a conceptual framework. RESULTS Five main themes and 13 subthemes emerged from the data. The five main themes, which mapped to the conceptual framework, were: recognition that the patient is dying; communication with the patient, family and other staff; involvement of the patient and family in their care; support for the dying person and their family; and planning and carrying out good care of the dying. Examples of when things are done poorly or done well were shared, giving context to experience. CONCLUSIONS Areas for improvement were identified around all five main themes. These will be useful for informing those involved in undergraduate and foundation training on how to improve the experiences of Foundation Year doctors and thereby improve patient care.
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Affiliation(s)
- Melody Redman
- Centre for Educational Development, Hull York Medical School, York, UK
| | - Jessica Pearce
- Centre for Educational Development, Hull York Medical School, York, UK
| | - Sareena Gajebasia
- Centre for Educational Development, Hull York Medical School, York, UK
| | - Miriam Johnson
- Centre for Educational Development, Hull York Medical School, York, UK
| | - Gabrielle Finn
- Centre for Educational Development, Hull York Medical School, York, UK
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