Good Quality Care for Cancer Patients Dying in Hospitals, but Information Needs Unmet: Bereaved Relatives' Survey within Seven Countries

Hospital care for the dying patient with cancer: does an advance care planning invitation influence bereaved relatives' experiences? A two country survey

OBJECTIVES

Advance care planning (ACP) is not systematically performed in Argentina or Norway. We used the post-bereavement survey of the ERANet-LAC International Care Of the Dying Evaluation (CODE) project (2017-2020) to examine the proportion of relatives who were offered an ACP conversation, the proportion of those not offered it who would have wanted it and whether the outcomes differed between those offered a conversation and those not.

METHODS

Relatives after cancer deaths in hospitals answered the CODE questionnaire 6-8 weeks post bereavement, by post (Norway) or interview (Argentina). Two additional questions asked if the relative and patient had been invited to a conversation about wishes for the patient's remaining lifetime, and, if not invited, whether they would have wanted such a conversation. The data were analysed using mixed-effects ordinal regression models.

RESULTS

276 participants (Argentina 98 and Norway 178) responded (56% spouses, 31% children, 68% women, age 18-80+). Fifty-six per cent had been invited, and they had significantly more positive perceptions about care and support than those not invited. Sixty-eight per cent of the participants not invited would have wanted an invitation, and they had less favourable perceptions about the care, especially concerning emotional and spiritual support.

CONCLUSIONS

Relatives who had been invited to a conversation about wishes for the patient's remaining lifetime had more positive perceptions about patient care and support for the relatives in the patient's final days of life. A majority of the relatives who had not been invited to an ACP conversation would have wanted it.

Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic

Background

The COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations.

Methods

A longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD.

Results

At baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions.

Conclusion

Results suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses).

Racial and ethnic disparities in end-of-life care for patients with oesophageal cancer: death trends over time

Background

Given significant morbidity and mortality associated with oesophageal cancer, supportive, high-quality end-of-life care is critical. Most patients with advanced cancer prefer to die at home, but incongruence between preferred and actual place of death is common. Here, we examined trends and disparities in location of death among patients with oesophageal cancer.

Methods

Using the Centers for Disease Control and Prevention Wide-Range Online Data for Epidemiologic Research database, we utilized multinomial logistic regression to assess associations between sociodemographic characteristics and location of death for patients with oesophageal cancer (n = 237,063). Additionally, we utilized linear regression models to evaluate the significance of changes in location of death trends over time and disparities in the relative change in location of death trends across sociodemographic groups.

Findings

From 2003 to 2019, there was a decrease of deaths in hospitals, nursing homes, and outpatient medical facilities/emergency departments and an increase of deaths at home and in hospice. Relative to White decedents, Black and Asian decedents were less likely to die at home (relative risk ratio (RRR): 0.58 [95% confidence interval (CI): 0.56-0.60], RRR: 0.57 [95% CI: 0.53-0.61]) and in hospice (RRR: 0.67 [95% CI: 0.64-0.71], RRR: 0.49 [95% CI: 0.43-0.55]) when compared to the hospital. Similar disparities were noted for American Indian and Alaska Native (AIAN) decedents. These disparities persisted even upon stratifying by the number of listed causes of death, a proxy for severity of illness. Time trend analysis indicated that increases in deaths in hospice over time occurred at a slower rate for AIAN and Asian decedents relative to White decedents.

Interpretation

2 in 5 patients with oesophageal cancer die at home, with an increasing proportion dying at home and in hospice-in line with general patient preferences. However, location of death disparities have largely persisted over time among racial and ethnic minority groups. Our findings suggest the importance of improving access to advance care planning and delivering tailored, person-centred interventions.

Funding

None.

What do bereaved relatives of cancer patients dying in hospital want to tell us? Analysis of free-text comments from the International Care of the Dying Evaluation (i-CODE) survey: a mixed methods approach

PURPOSE

We conducted an international survey of bereaved relatives of cancer patients dying in hospitals in seven countries, with the aim to assess and improve the quality of care. The survey used the i-CODE (International Care of the Dying Evaluation) questionnaire. Here, we report findings from the free-text comments submitted with the questionnaires. We explored for topic areas which would potentially be important for improving the quality of care. Further, we examined who reported free-texts and in what way, to reduce bias without ignoring the function the free-texts may have for those contributing.

METHODS

We used a combined qualitative-quantitative approach: logistic regression analysis to study the effect of respondents' socio-demographic characteristics on the probability of free-texts contributions and thematic analysis to understand the free-text meaning. The primary survey outcomes, (1) how frequently the dying person was treated with dignity and respect and (2) support for the relative, were related to free-text content.

RESULTS

In total, 914 questionnaires were submitted; 457/914 (50%) contained free-text comments. We found no socio-demographic differences between the respondents providing free-texts and those who did not. We discovered different types of free-texts ("feedback," "narrative," "self-revelation") containing themes of which "continuity of care," "the one person who can make a difference," and "the importance of being a companion to the dying" represent care dimensions supplementing the questionnaire items. A free-text type of grateful feedback was associated with well perceived support for the relative.

CONCLUSION

Bereaved relatives used the free-texts to report details related to i-CODE items and to dimensions otherwise not represented. They highlighted the importance of the perceived support from human interaction between staff and the dying patient and themselves; and that more than professional competence alone, personal, meaningful interactions have profound importance.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

Psychosocial factors affecting the bereavement experience of relatives of palliative-stage cancer patients: a systematic review

BACKGROUND

Cancer is one of the leading causes of death worldwide and a cancer death is a major risk factor for pathological bereavement. This systematic review of the literature aimed to identify biopsychosocial and existential determinants specific to the palliative phase of cancer that influence the grieving experience of the caregiving relative.

METHOD

A systematic review of the literature was conducted without language or time restrictions. The Cairn, Cochrane Library, PubMed, PsycArticle, PsychInfo, Psychology and Behavioral Sciences Collection databases were explored. All studies assessing pre- and post-death measures and focusing on friends and relatives caring for adults with cancer in palliative care services were included in the review.

RESULTS

Out of 645 articles identified, 18 full text studies were finally included in our systematic review of the literature. Many factors specific to the cancer palliative phase were identified as influencing the bereavement experience of caregivers, with factors relating to: 1) the caregiver (e.g. social support, psychological burden, preparation for loss, action and discussion related to death); 2) the patient (e.g. denial or acceptance); 3) the interactions between patient and their caregivers (e.g. tensions, communication difficulties, and presence at the time of death); and 4) the end-of-life context. The caregiver's grief experience can be described by the following terms: typical and pathological grief, anxiety, depression, guilt, psychological distress, post-traumatic stress disorder and post-traumatic growth, and life satisfaction.

CONCLUSIONS

 Many contextual, sociodemographic, dispositional and transactional factors specific to the palliative cancer phase are involved in the caregiver's grieving experience. Avenues for reflection and recommendations are proposed including supporting communication and patient-relative relationships, evaluating the nature and degree of functionality of coping strategies, strengthening the robustness of methodologies, considering impact of COVID-19, and new lines of enquiry for research.

Validation of 'Care Of the Dying Evaluation' (CODETM) within an international study exploring bereaved relatives' perceptions about quality of care in the last days of life

CONTEXT

Assessing quality of care provided during the dying phase using validated tools aids quality assurance and recognizes unmet need.

OBJECTIVE

To assess construct validity and internal consistency of 'Care Of the Dying Evaluation' (CODE^TM) within an international context.

METHODS

Post-bereavement survey (August 2017 to September 2018) using CODE^TM. Respondents were next-of-kin to adult patients (≥ 18 years old) with cancer who had an 'expected' death within 22 study site hospitals in 7 countries: Argentina, Brazil, Germany, Norway, Poland, United Kingdom, Uruguay. Exploratory and Confirmatory Factor Analysis (EFA and CFA) were conducted, and internal reliability was assessed using Cronbach alpha (α). Known group validity was assessed by ability to discriminate quality of care based in place (Palliative Care Units (PCUs)) and country (Poland, where most deaths were in PCUs) of care. Differences were quantified using effect sizes (ES).

RESULTS

A 914 CODE^TM questionnaires completed (54% response rate). 527 (58%) male deceased patients; 610 (67%) next-of-kin female who were most commonly the 'spouse/partner' (411, 45%). EFA identified 4 factors: 'Overall care,' 'Communication and support,' 'Trust, respect and dignity,' and 'Symptom management' with good reliability scores (α = 0.628 - 0.862). CFA confirmed the 4-factor model; these were highly correlated and a bifactor model showed acceptable fit. The ES for quality of care in PCU's was 0.727; ES for Poland was 0.657, supporting the sensitivity of CODE^TM to detect differences.

CONCLUSION

Within an international context, good evidence supports the validity and reliability of CODE^TM for assessing the quality of care provided in the last days of life.

Risk factors associated with poorer experiences of end-of-life care and challenges in early bereavement: Results of a national online survey of people bereaved during the COVID-19 pandemic

BACKGROUND

Experiences of end-of-life care and early bereavement during the COVID-19 pandemic are poorly understood.

AIM

To identify clinical and demographic risk factors for sub-optimal end-of-life care and pandemic-related challenges prior to death and in early bereavement, to inform clinical practice, policy and bereavement support.

DESIGN

Online national survey of adults bereaved in the UK (deaths between 16 March 2020 and 2 January 2021), recruited via media, social media, national associations and organisations.

SETTING/PARTICIPANTS

711 participants, mean age 49.5 (SD 12.9, range 18-90). 628 (88.6%) were female. Mean age of the deceased was 72.2 (SD 16.1, range miscarriage to 102 years). 311 (43.8%) deaths were from confirmed/suspected COVID-19.

RESULTS

Deaths in hospital/care home increased the likelihood of poorer experiences at the end of life; for example, being unable to visit or say goodbye as wanted (p < 0.001). COVID-19 was also associated with worse experiences before and after death; for example, feeling unsupported by healthcare professionals (p < 0.001), social isolation/loneliness (OR = 0.439; 95% CI: 0.261-0.739), and limited contact with relatives/friends (OR = 0.465; 95% CI: 0.254-0.852). Expected deaths were associated with a higher likelihood of positive end-of-life care experiences. The deceased being a partner or child also increased the likelihood of positive experiences, however being a bereaved partner strongly increased odds of social isolation/loneliness, for example, OR = 0.092 (95% CI: 0.028-0.297) partner versus distant family member.

CONCLUSIONS

Four clear risk factors were found for poorer end-of-life care and pandemic-related challenges in bereavement: place, cause and expectedness of death, and relationship to the deceased.

Prognostication of the last days of life: Review article

Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.

One chance to get it right: improving clinical handovers for better symptom control at the end of life

Poor communication contributes to morbidity and mortality, not only in general medical care but also at the end oflife. This leads to issues relating to symptom control and quality of care. As part of an international project focused on bereaved relatives' perceptions about quality of end-of-life care, we undertook a quality improvement (QI) project in a general hospital in Córdoba city, Argentina.By using two iterative QI cycles, we launched an educational process and introduced a clinical mnemonic tool, I-PASS, during ward handovers. The introduction of the handover tool was intended to improve out-of-hours care.Our clinical outcome measure was ensuring comfort in at least 60% of dying patients, as perceived by family carers, during night shifts in an oncology ward during the project period (March-May 2019). As process-based measures, we selected the proportion of staff completing the I-PASS course (target 60%) and using I-PASS in at least 60% of handovers. Participatory action research was the chosen method.During the study period, 13/16 dying patients were included. We received 23 reports from family carers about the level of patient comfort during the previous night.Sixty-five per cent of healthcare professionals completed the I-PASS training. The percentage of completed handovers increased from 60% in the first Plan-Do-Study-Act (PDSA) cycle to 68% in the second one.The proportion of positive reports about patient comfort increased from 63% (end of the first PDSA cycle) to 87% (last iterative analysis after 3 months). Moreover, positive responses to 'Did doctors and nurses do enough for the patient to be comfortable during the night?' increased from 75% to 100% between the first and the second QI cycle.In conclusion, we achieved the successful introduction and staff training for use of the I-PASS tool. This led to improved perceptions by family carers, about comfort for dying patients.