Hospice at home service: the carer's perspective

Home care nurses facilitating planned home deaths. A focused ethnography

BACKGROUND

Home care nurses provide complex palliative care for patients who want to die in their own homes. This study aimed to explore home care nurses' facilitation of planned home death to better understand nursing practices.

METHODS

Data were collected between March 2019 and March 2020 using participant observations and semi-structured interviews. In addition, the number of planned home deaths was recorded. The analysis was guided by Roper and Shapira`s framework on focused ethnography.

RESULTS

Twenty home care nurses (three men) in eight home care areas in two Norwegian municipalities met the inclusion criteria. Eight home deaths were registered, seven participatory observations were performed, and 20 semi-structured interviews were completed. Home care nurses find facilitating planned home deaths to be rewarding work, to the point of going above and beyond. At the same time, they describe facilitating planned home deaths as demanding work due to organizational stressors such as staff shortages, heavy workloads, and time restraints. While they tend to patients' needs, they also express concern for the wellbeing of the next of kin. They find it challenging to juggle the needs of the patients with the needs of next of kin, as these are not always correlated.

CONCLUSION

Home care nurses are pushing the boundaries of their practice when facilitating planned home deaths while compensating for a fragile system by going above and beyond for patients and their next of kin. Providing insights into the work of home care nurses providing palliative care in patients' homes can impact recruiting and retaining nurses in the workforce and influence local practices and policies.

Hospice at Home services in England: a national survey

OBJECTIVE

Hospice at Home (HAH) services aim to enable patients to be cared for and die at home, if that is their choice and achieve a 'good death'. A national survey, in 2017, aimed to describe and compare the features of HAH services and understand key enablers to service provision.

METHODS

Service managers of adult HAH services in the 'Hospice UK' and National Association for Hospice at Home directories within England were invited to participate. Information on service configuration, referral, staffing, finance, care provision and enablers to service provision were collected by telephone interview.

RESULTS

Of 128 services invited, 70 (54.7%) provided data. Great diversity was found. Most services operated in mixed urban/rural (74.3%) and mixed deprivation (77.1%) areas and provided hands-on care (97.1%), symptom assessment and management (91.4%), psychosocial support (94.3%) and respite care (74.3%). Rapid response (within 4 hours) was available in 65.7%; hands-on care 24 hours a day in 52.2%. Charity donations were the main source of funding for 71.2%. Key enablers for service provision included working with local services (eg, district nursing, general practitioner services), integrated health records, funding and anticipatory care planning. Access to timely medication and equipment was critical.

CONCLUSION

There is considerable variation in HAH services in England. Due to this variation it was not possible to categorise services into delivery types. Services work to supplement local care using a flexible approach benefitting from integration and funding. Further work defining service features related to patient and/or carer outcomes would support future service development.

Pacific meets west in addressing palliative care for Pacific populations in Aotearoa/New Zealand: a qualitative study

BACKGROUND

While many Aotearoa/New Zealanders are receiving excellent palliative care the Pacific populations have limited access to available hospice and palliative care services. Little research has been conducted to identify barriers unique to Pacific populations accessing these services. The purpose of this study was to explore key stakeholders' perspectives on the determinants of low access among Pacific populations to these services.

METHODS

Forty-five semi-structured interviews were conducted face-to-face with hospice patients and their families, hospice/health providers and key informants from the Auckland and Wellington region of Aotearoa/New Zealand. The interviews were recorded and transcribed verbatim and a thematic analysis was carried out by identifying, coding and categorising patterns in the data. Identified themes were then discussed further to determine the relevance of the data grouped by theme.

RESULTS

Five interrelated themes affecting access emerged: perception of hospice (often negative) through lack of accurate information, but changing; families' role to look after their own and sick elderly; hospice experiences; continuity of care in the community and the need for information and communication.

CONCLUSION

Hospice and associated palliative care services are under-utilised and commonly misunderstood among Pacific populations in Aotearoa/New Zealand. There is active support following appropriate information received, hence the need for community education and culturally appropriate hospice and palliative services. Inadequate inter-professional communication contributes to polypharmacy and inefficiency in continuity of care across all levels. The Pacific individual is one component of a collective that is critical in major decisions in end-of-life and life changing situations. The findings may guide policies and further research to improve Hospice and Palliative services in Aotearoa/New Zealand.

Unmet needs of patients with cancer in their last year of life as described by caregivers in a developing world setting: a qualitative study

BACKGROUND

Palliative care is in its infancy in most of the developing world. We set out to explore the lived experiences of families and caregivers of recently deceased cancer patients in Trinidad and Tobago and to determine the unmet needs of the patients and what recommendations could be derived to improve the current services.

METHODS

A phenomenological approach with purposeful sampling was used. Participants were referred by key health professionals. Face-to-face interviews were conducted. Interviews were transcribed verbatim, with analysis and data collection occurring concurrently. Thematic content analysis was used to determine common domains, themes and sub-themes.

RESULTS

Interviews were completed with 15 caregivers. All were spouses or children of the deceased. Ages of the deceased ranged from 43 to 93, the average being 65.5 years. The deceased experienced a variety of cancers including lung, colorectal and oesophageal. Unmet needs were identified under 4 domains of institutions, community, the family unit and the wider society. Institutional unmet needs were delayed diagnosis and treatment and poor inter-institution coordination. Medical and nursing care failed in the areas of health care providers' attitudes, pain management and communication. The family unit lacked physical and psychosocial support for the caregiver and financial aid for the family unit. Societal needs were for public education to address myths and cultural beliefs around cancer.

CONCLUSION

There is need for systemic interventions to improve the care of those dying from cancer in Trinidad and Tobago. Stakeholders need to commit to palliative care as a public health priority, implementing education, planning services and mobilizing community resources.

Understanding what works, why and in what circumstances in hospice at home services for end-of-life care: Applying a realist logic of analysis to a systematically searched literature review

BACKGROUND

We have undertaken a systematically searched literature review using a realist logic of analysis to help synthesise the diverse range of literature available on hospice at home services.

AIM

To find out in the existing literature what features of hospice at home models work best, for whom and under what circumstances.

DESIGN

A realist logic of analysis was applied to synthesise the evidence focusing on mechanisms by which an intervention worked (or did not work). An initial programme theory was developed using the National Association for Hospice at Home standards, Normalisation Process Theory and through refinement using stakeholder engagement.

DATA SOURCES

PubMed, Science Direct, AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsychINFO, SCOPUS, Web of Science, DARE, Google Scholar, NHS Evidence, NIHR CRN portfolio database, NIHR journal library of funded studies, including searches on websites of relevant professional bodies (August 2014, June 2017, June 2019).

RESULTS

Forty-nine papers were reviewed, of which 34 contributed evidence to at least one of the eight theory areas: marketing and referral, sustainable funding model, service responsiveness and availability, criteria for service admission, knowledge and skills of care providers, integration and coordination, anticipatory care, support directed at carers.

CONCLUSIONS

Our literature review showed how it was possible to develop a coherent framework and test it against 34 published papers and abstracts. Central to this review was theory building, and as further evidence emerges, our programme theories can be refined and tested against any new empirical evidence.

The significance of gratitude for palliative care professionals: a mixed method protocol

BACKGROUND

In palliative care (PC) patients and relatives (P/R) often show their gratitude to the healthcare professionals (HP) who care for them. HP appreciate these displays of gratitude, although the impact of the same has not been examined in detail. Publications analysed tell personal experiences in which HP say that displays of gratitude create sensations of well-being, pride and increased motivation to carry on caring. No systematic examination in PC was found. These aspects related to gratitude may be important in the field of PC, where there is constant exposure to suffering and the preoccupation which arises from wanting to help HP to go on with their work, but it needs closer study and systemisation. The purpose of this study is to understand the significance and the role of the gratitude received from P/R for palliative care health professionals (PCHP).

METHODS

A suitable mixed method will be used. The first phase will be quantitative and will consist of a survey, piloted by experts, whose goal is to explore the current situation in Spain as regards displays of gratitude received by HP at PC services. It will be sent by e-mail. The results from this part will be incorporated into the second part which will be qualitative and whose goal is to understand the significance of the experience of receiving displays of gratitude from the perspective of PCHP, using a phenomenological approach. Interviews will be undertaken amongst PCHP. The interview guide will be designed after taking the survey results into account. The project has been granted ethical approval.

DISCUSSION

These results are set to provide a key contribution within the context of the growing preoccupation on how to care for HP, how to ensure retention and keep them from resigning, as well as preventing burnout, emotional fatigue and boosting their resilience. In order to do this, it is both interesting and ground breaking, to analyse the repercussion of spontaneous gratitude shown by P/R towards PCHP, to see if this is a useful resource to reduce these problems and to encourage the greater presence of dignity and humanisation, for both those receiving care and for those providing it. This gratitude may be one of these strategies.

What do patients and family-caregivers value from hospice care? A systematic mixed studies review

BACKGROUND

It is not known which attributes of care are valued the most by those who experience hospice services. Such knowledge is integral to service development as it facilitates opportunities for continuous improvement of hospice care provision. The objectives of this mixed-studies systematic review were to explore patients' and their family carer views and experiences, to determine what they valued about adult hospice care in the UK.

METHODS

ASSIA, PubMed, CINAHL and PsycINFO were searched from inception, up until March 2017 to identify qualitative, quantitative, and mixed-methods studies. Four additional searching techniques supplemented the main search and grey literature was included. A three-stage mixed-method systematic review was conducted with a sequential exploratory design. Thematic synthesis was used with qualitative data, followed by a narrative summary of the quantitative data. The qualitative and quantitative syntheses were then juxtaposed within a matrix to produce an overarching synthesis.

RESULTS

Thirty-four studies highlighted that what patients and carers valued was generally context specific and stemmed from an amalgamation of hospice service components, which both individually and collectively contributed to improvements in quality of life. When the syntheses of qualitative and quantitative studies were viewed in isolation, the value placed on services remained relatively consistent, with some discrepancies evident in service availability. These were commonly associated with geographical variations, as well as differences in service models and timeframes. Through an overarching synthesis of the qualitative and quantitative evidence, however, notable variations and a more nuanced account of what people valued and why were more prominent, specifically in relation to a lack of social support for carers, disparate access to essential services, the underrepresentation of patients with a non-cancer diagnosis, and the dissatisfaction with the range of services provided.

CONCLUSION

Review findings strengthen the existing evidence base and illuminates the underpinning elements of hospice care most valued by patients and their families. With large disparities in the availability of services, however, the underrepresentation of patients with non-malignant diseases and the limited evidence base demonstrating the adequate addressment of the social needs of carers, there continues to be considerable gaps that warrants further research.

“What She Told Us Made the world of Difference”: Carers’ Perspectives on A Hospice at Home Service

This paper explores the expectations and needs of current and bereaved carers whose relatives received care at home from a palliative care team. Aim: A hospice at home service was established in 2006 to provide patients with care in their own homes. We examined whether this model of care was helpful in mitigating carers’ burden and in enabling terminally ill patients to be cared for and die at home. Methods: This study utilized a survey and interviews. Participants were carers in the midwest of Ireland. Survey responses from 122 carers were analyzed using SPSS 18.0 (SPSS Inc., 2009); interviews with 15 carers were also conducted. Results: Carers’ expectations of the service were often exceeded, and quality of care dimensions were rated highly. Future improvements could include facilitating discussions on place of death and offering bereavement support. Conclusion: The service is supporting carers in facilitating their relatives’ choice to die at home.

Experiences and needs of Bereaved Carers during Palliative and End-Of-Life Care for People with Chronic Obstructive Pulmonary Disease

Aim: This study explored the experiences of palliative care that bereaved carers had while providing care to a dying loved one with chronic obstructive pulmonary disease (COPD). Method: Semi-structured interviews were undertaken with nine carers who had lost a loved one in the preceding 6 to 24 months. These interviews explored levels of satisfaction with disease management, symptom management, and end-of-life care. With permission, interviews were tape recorded, transcribed, and subjected to content analysis. Findings: Three themes emerged from the data: the impact of the caring experience, the lack of support services, and end-of-life and bereavement support. Carers experienced carer burden, lack of access to support services, a need for palliative care, and bereavement support. Conclusion: The findings provide a first insight into the experiences of carers of patients with advanced COPD. Bereaved carers of patients who had suffered advanced COPD reported that they had received inadequate support and had a range of unmet palliative care needs. Special attention should be paid to educating and supporting carers during their caring and bereavement periods to ensure that their quality of life is maintained or enhanced.

Optimum hospice at home services for end-of-life care: protocol of a mixed-methods study employing realist evaluation

INTRODUCTION

Hospice at home (HAH) services aim to enable patients to be cared for and die in their place of choice, if that is at home, and to achieve a 'good death'. There is a considerable range of HAH services operating in England. The published evidence focuses on evaluations of individual services which vary considerably, and there is a lack of consistency in terms of the outcome measures reported. The evidence, therefore, does not provide generalisable information, so the question 'What are the features of hospice at home service models that work, for whom, and under what circumstances?' remains unanswered. The study aims to answer this question.

METHODS AND ANALYSIS

This is a mixed-methods study in three phases informed by realist evaluation methodology. All HAH services in England will be invited to participate in a telephone survey to enable the development of a typology of services. In the second phase, case study sites representing the different service types will collect patient data and recruit carers, service managers and commissioners to gather quantitative and qualitative data about service provision and outcomes. A third phase will synthesise and refine the results through consensus workshops.

ETHICS AND DISSEMINATION

The first survey phase has university ethics approval and the second phase, Integrated Research Application System (IRAS) and Health Research Authority (HRA) approval (IRAS ID:205986, REC:17/LO/0880); the third phase does not require ethics approval. Dissemination will be facilitated by project coapplicants with established connections to national policy-making forums, in addition to publications, conference presentations and reports targeted to service providers and commissioners.

'The importance of planning for the future': Burden and unmet needs of caregivers' in advanced heart failure: A mixed methods study

BACKGROUND

While studies have evaluated caregiver outcomes in heart failure, the burden and support needs when caring for someone with advanced heart failure at the end of life have yet to be outlined.

AIM

To identify psychosocial factors associated with caregiver burden and evaluate the support needs of caregivers in advanced heart failure.

DESIGN

A sequential mixed methods study comprising two phases: (1) postal survey with advanced heart failure patients and their caregivers and (2) interviews with current and bereaved caregivers. Correlation, chi-square, t test, regression and thematic analysis were undertaken on the data.

PARTICIPANTS

Advanced heart failure patients ( n = 112) and their caregivers ( n = 84) were recruited from secondary care settings across the United Kingdom and Ireland. For phase 2 interviews, current caregivers ( n = 20) were purposively recruited from phase 1, and bereaved caregivers ( n = 10) were purposively recruited via voluntary organisation, social media and email.

RESULTS

More than half the caregivers (53%) had levels of distress associated with depression (Zarit Burden score >24). Caregiver depression score, preparedness for caregiving and patients' depression score predicted caregiver burden. Qualitative analysis identified an overarching theme of lack of future care planning and four subthemes: (1) seeking emotional support from someone who understands, (2) want information on prognostication, (3) lack of knowledge on how to and where to get support and (4) require knowledge on what to expect at the end of life.

CONCLUSION

Caregivers have unmet needs and feel unprepared for the future. Implementation of future care planning by clinical teams should address patient and caregiver support needs and in turn alleviate caregiver burden.

Supporting home hospice family caregivers: Insights from different perspectives

ABSTRACTObjective:Our intention was to describe and compare the perspectives of national hospice thought leaders, hospice nurses, and former family caregivers on factors that promote or threaten family caregiver perceptions of support.

METHOD

Nationally recognized hospice thought leaders (n = 11), hospice nurses (n = 13), and former family caregivers (n = 14) participated. Interviews and focus groups were audiotaped and transcribed. Data were coded inductively, and codes were hierarchically grouped by topic. Emergent categories were summarized descriptively and compared across groups.

RESULTS

Four categories linked responses from the three participant groups (95%, 366/384 codes): (1) essentials of skilled communication (30.6%), (2) importance of building authentic relationships (28%), (3) value of expert teaching (22.4%), and (4) critical role of teamwork (18.3%). The thought leaders emphasized communication (44.6%), caregivers stressed expert teaching (51%), and nurses highlighted teamwork (35.8%). Nurses discussed teamwork significantly more than caregivers (z = 2.2786), thought leaders discussed communication more than caregivers (z = 2.8551), and caregivers discussed expert teaching more than thought leaders (z = 2.1693) and nurses (z = 2.4718; all values of p < 0.05).

SIGNIFICANCE OF RESULTS

Our findings suggest differences in priorities for caregiver support across family caregivers, hospice nurses, and thought leaders. Hospice teams may benefit from further education and training to help cross the schism of family-centered hospice care as a clinical ideal to one where hospice team members can fully support and empower family caregivers as a hospice team member.

Persistent inequalities in Hospice at Home provision

OBJECTIVE

To describe the nature and scope of a new Hospice at Home (H@H) service and to identify its equality of provision.

METHODS

Case note review of patients supported by a H@H service for 1 year from September 2012 to August 2013 (n=321). Descriptive analysis to report frequencies and proportions of quantitative data extracted from service logs, referral forms and care records; thematic analysis of qualitative data from care record free text.

RESULTS

Demand outstripped supply. Twice as many night care episodes were requested (n=1237) as were provided (n=613). Inequalities in access to the service related to underlying diagnosis and socioeconomic status. 75% of patients using the service had cancer (221/293 with documented diagnosis). Of those who died at home in the areas surrounding the hospice, 53% (163/311) of people with cancer and 11% (49/431) of those without cancer received H@H support. People who received H@H care were often more affluent than the population average for the area within which they lived. Roles of the service identified included: care planning/implementation, specialist end-of-life care assessment and advice, 'holding' complex patients until hospice beds become available and clinical nursing care.

CONCLUSION

There is significant unmet need and potentially large latent demand for the H@H service. People without cancer or of lower socioeconomic status are less likely to access the service. Action is needed to ensure greater and more equitable service provision in this and similar services nationally and internationally.

Barriers and facilitators influencing death at home: A meta-ethnography

BACKGROUND

In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach.

AIM

To identify and understand the barriers and facilitators influencing death at home.

DESIGN

Meta-ethnography.

DATA SOURCES

The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis.

RESULTS

A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication.

CONCLUSION

Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services.

Supporting family carers providing end-of-life home care: a qualitative study on the impact of a hospice at home service

AIMS AND OBJECTIVES

To explore bereaved family carers' perceptions and experiences of a hospice at home service.

BACKGROUND

The increasing demand for the development of home-based end-of-life services is not confined to the western world; such services are also emerging in resource-poor countries where palliative care services are developing with limited inpatient facilities. Despite this growing trend, studies show a variety of interrelated factors, with an emphasis on the availability of informal carers and their ability to cope, which can influence whether terminally ill patients actually remain at home. A hospice at home service was developed to meet patients' and families' needs by providing individually tailored resources.

DESIGN

A qualitative study.

METHODS

Data were collected by semi-structured, digitally recorded interviews from 20 family carers who had experienced the service. Interviews were transcribed verbatim and a thematic approach adopted for analysis.

RESULTS

All participants reported a personal positive impact of the service. Family carers commented the service provided a valued presence, they felt in good hands and importantly it helped in supporting normal life.

CONCLUSIONS

The impact of an individualised, targeted, hospice at home service using dedicated, palliative care trained, staff, is perceived positively by family carers and importantly, supportive of those with additional caring or employment commitments.

RELEVANCE TO CLINICAL PRACTICE

The emergence of hospice at home services has resulted in more options for patients and their families, when the increased amount of care a family member has to provide in these circumstances needs to be adequately supported, with the provision of a flexible service tailored to individual needs and delivered by appropriately trained staff.

A family's difficulties in caring for a cancer patient at the end of life at home in Japan

CONTEXT

Most people hoped for home care at the end of life and death at home in Japan. However, the rate for death at home from cancer in Japan is less than 10% of the total deaths of cancer patients.

OBJECTIVES

The aim of this study was to investigate circumstances, difficulties, and correlated factors for family caregivers who provided care at home for a family member with terminal cancer.

METHODS

The Family's Difficulty Scale for end-of-life home care questionnaire was sent to 395 bereaved family caregivers who had cared for a terminal cancer patient with the assistance of home services.

RESULTS

We obtained 306 responses for a response rate of 81%. The results showed that family caregivers had a high rate of difficulties related to "Patient's pain and condition" (64%~90%) and "Burden of care" (61%~78%). A logistic regression analysis was performed on the data to examine factors related to the difficulties. More difficulties occurred for male caregivers (odds ratio [OR]=0.39, P=0.04) who did not prefer for the patient to die at home (OR=0.42, P=0.01).

CONCLUSION

This study indicates that it is important for home care providers to introduce services to reduce care burden. In addition, a thorough explanation of the patient's symptoms and condition is necessary to reduce distress and anxiety for family caregivers.

Legitimising and rationalising in talk about satisfaction with formal healthcare among bereaved family members

While there is a fair amount of knowledge regarding substantive features of end of life care that family members desire and appreciate, we lack full understanding of the process whereby family members formulate care evaluations. In this article we draw on an analysis of interview data from 24 bereaved family members to explicate how they interpret their experiences and formulate evaluations of end of life care services. Most participants wove between expressing and legitimising dissatisfaction, and qualifying or diffusing it. This occurred through processes of comparisons against prior care experiences and expectations, personalising (drawing on personal situations and knowledge), collectivising (drawing on conversations with and observations of others) and attempting to understand causes for their negative care experiences and to attribute responsibility. The findings suggest that dissatisfaction might be diffused even where care is experienced negatively, primarily through the acknowledgement of mitigating circumstances. To a lesser extent, some participants attributed responsibility to the 'system' (policy and decision-makers) and individual staff members. The findings are discussed in relation to the theoretical understanding of satisfaction and evaluation processes and how satisfaction data might inform improvements to care quality.

Guidelines for the psychosocial and bereavement support of family caregivers of palliative care patients

BACKGROUND

Support for family caregivers, including bereavement follow-up, is a core function of palliative care. Many caregivers acknowledge positive aspects associated with the role; however a considerable proportion will experience poor psychological, social, financial, spiritual, and physical well-being and some will suffer from complicated grief. Many family caregivers have unmet needs and would like more information, preparation, and support to assist them in the caregiving role. There is a shortage of evidence-based strategies to guide health professionals in providing optimal support while the caregiver is providing care and after the patient's death.

PURPOSE

To develop clinical practice guidelines for the psychosocial and bereavement support of family caregivers of palliative care patients.

METHODS

(1) Literature review; (2) focus groups and structured interviews with key stakeholders within Australia; (3) national and international expert opinion to further develop and refine the guidelines using a modified Delphi process; and (4) endorsement of the guidelines from key palliative care, caregiver, and bereavement organizations (national and international).

RESULTS

The guidelines were developed for multidisciplinary health care professionals and clinical services commonly involved in caring for adult patients receiving palliative care in a variety of care sites throughout Australia. These consensus-based guidelines have been endorsed key Australian and international organizations.

CONCLUSIONS

The guidelines may prove valuable for the international palliative care community and for generalist health care providers who occasionally care for palliative care patients. Research is recommended to explore the uptake, implementation, and effectiveness of the guidelines.

How can informal caregivers in cancer and palliative care be supported? An updated systematic literature review of interventions and their effectiveness

INTRODUCTION

Informal caregivers needs in cancer/advanced disease are largely unmet. The science of carer intervention evaluation is methodologically challenging, and the evidence historically weak.

OBJECTIVE

This systematic review updates an earlier effectiveness review to determine both the effectiveness of subsequently published intervention studies, and the current state of science.

METHOD

The evidence was identified and appraised using a comprehensive search strategy. Articles were searched from 2001 to 2010 using the following electronic databases: Medline, PsychINFO and CINAHL. Inclusion criteria were studies reporting intervention data for informal adult caregivers of a patient with a diagnosis of cancer or receiving palliative care. The design and evidence rigour were assessed using the Jadad Rating Scale, and the Quality Rating Scale.

RESULTS

33 studies met inclusion criteria. From the original review, an encouraging increase was identified in the number of evaluations (from 8 to 33), in carer-specific interventions (from 6 to 17) and in the robustness of the study design (an increase from 2 to 12 studies with before/after measures, comparison groups and prospective data).

CONCLUSIONS

The evidence suggests a rapid increase in the number of robust intervention studies. However, the range of models remains narrow in relation to caregivers' needs and preferences.

Exploring Family Caregivers’ Rationales for Nonuse of Formal Home Health Services When Caring for a Dying Family Member

Drawing on interviews with 26 bereaved individuals who provided care to a dying family member at home, the purpose of this article is to identify and explore motivations behind the “nonuse” of home health services. Participants resided in a Western Canadian regional health authority. In their accounts of not asking for help from formal providers, participants highlighted personal reasons, coping needs, and a lack of knowledge. In their accounts of refused help, they placed more emphasis on a perceived lack of need for help (including constructing themselves as capable and coping), as well as their perceptions of the quality and competence of formal services. Findings are compared against existing literature. Implications for health system policy and planning, and for home health nursing practice, training and education, particularly with reference to situations in which responsibility is left with families to ask for help from formal providers, are also discussed.

What makes grief difficult? Perspectives from bereaved family caregivers and healthcare providers of advanced cancer patients

Objective:

Family members who take on the role of caregiving for someone who is dying begin bereavement after being emotionally and physically taxed by the caregiving experience. The course of bereavement is influenced by a number of factors, including health problems, financial concerns, social support, and family relationships. This paper reports on findings from a secondary analysis of qualitative data from a study examining family caregiver coping in end-of-life cancer care, to describe, from the perspectives of bereaved family caregivers, their perspectives on what made their grief difficult.

Method:

Qualitative data from three focus groups with family caregivers (n = 19) and two focus groups with health professionals (n = 14) were subjected to interpretive thematic analysis.

Results:

Our finding suggest three broad areas that make family caregivers' grief difficult: (1) dealing with occurrences in everyday life; (2) dealing with challenges specific to the caregiving situation; and (3) dealing with the healthcare system.

Significance of results:

The findings provide an important beginning point in understanding the types of issues that seem to make grief difficult for family caregivers of cancer patients at the end of life and can help professional groups to understand what is needed by family caregivers in terms of support and delivery of services.

Part 1: Home-based family caregiving at the end of life: a comprehensive review of published quantitative research (1998-2008)

The changing context of palliative care over the last decade highlights the importance of recent research on home-based family caregiving at the end of life. This article reports on a comprehensive review of quantitative research (1998-2008) in this area, utilizing a systematic approach targeting studies on family caregivers, home settings, and an identified palliative phase of care (n = 129). Methodological challenges were identified, including: small, non-random, convenience samples; reliance on descriptive and bivariate analyses; and a dearth of longitudinal research. Robust evidence regarding causal relationships between predictor variables and carer outcomes is lacking. Findings suggest the need for knowledge regarding: family caregiving for patients with non-malignant terminal conditions; whether needs and outcomes differ between family caregivers at the end of life and comparison groups; and caregiver outcomes in bereavement. Clear definitions of 'family caregiving', 'end of life', and 'needs' are required as well as greater application and testing of theoretical and conceptual explanations.

Part 2: Home-based family caregiving at the end of life: a comprehensive review of published qualitative research (1998-2008)

Family caregivers are crucial for supporting home death. We reviewed published qualitative research on home-based family caregiving at end of life (1998-2008), synthesizing key findings and identifying gaps where additional research is needed. Multiple databases were searched and abstracts reviewed for a focus on family caregiving and palliative care; full articles were reviewed to extract data for this review. In total, 105 articles were included. Findings are presented in the following areas: the caregiving experience and contextual features; supporting family caregivers at end of life; caregiving roles and decision-making; and rewards, meaning and coping. We noted a lack of definitional clarity; a reliance on interview methods and descriptive, thematic analyses, and a relative lack of diversity of patient conditions. Research needs are identified in several areas, including the bereavement experience, caregiver ambivalence, access to services, caregiver meaning-making, and relational and contextual influences on family caregiving at end of life.

On the notion of home and the goals of palliative care

The notion of home is well known from our everyday experience, and plays a crucial role in all kinds of narratives about human life, but is hardly ever systematically dealt with in the philosophy of medicine and health care. This paper is based upon the intuitively positive connotation of the term "home." By metaphorically describing the goal of palliative care as "the patient's coming home," it wants to contribute to a medical humanities approach of medicine. It is argued that this metaphor can enrich our understanding of the goals of palliative care and its proper objectives. Four interpretations of "home" and "coming home" are explored: (1) one's own house or homelike environment, (2) one's own body, (3) the psychosocial environment, and (4) the spiritual dimension, in particular, the origin of human existence. Thinking in terms of coming home implies a normative point of view. It represents central human values and refers not only to the medical-technical and care aspects of health care, but also to the moral context.

Situated/being situated: Client and co-worker roles of family caregivers in hospice palliative care

Since the inception of the modern hospice movement, the patient and family caregiver (FCG) have been considered the unit of care; family members are identified as 'clients' within palliative care philosophy. Little research has focused on how FCGs define their roles within the hospice palliative care (HPC) system. The aim of this study was to describe how FCGs of dying cancer patients view their roles in relation to the HPC system. Secondary analysis of interviews with 36 bereaved FCGs in Western Canada, guided by interpretive descriptive methods, found that FCGs perceived themselves as having two roles: client and co-worker. FCGs situated themselves as clients, where they actively sought help from the health care system. FCGs at times also perceived they had been situated as clients by health care providers, and were more resistant to accepting help. In other comments FCGs situated themselves as co-workers, seeking out an active role within the HPC team, whereas in other instances, felt they were situated as co-workers by a health care system with limited financial and human resources. Findings suggest that greater emphasis be placed on helping family members identify suitable interventions depending on how they view their roles within the HPC system. How we define family members in relation to the HPC system may also require reconsideration to reflect a more current conceptualization of realities in end-of-life care.

Bereaved family members' evaluation of hospice care: what factors influence overall satisfaction with services?

As patients near the end of life, bereaved family members provide an important source of evaluation of the care they receive. A study was conducted to identify which processes of care were associated with greater satisfaction with hospice services from the perception of bereaved family members. A total of 116,974 surveys from 819 hospices in the United States were obtained via the 2005 Family Evaluation of Hospice Care, an online repository of surveys of bereaved family members' perceptions of the quality of hospice care maintained by the National Hospice and Palliative Care Organization. Overall satisfaction was dichotomized as "excellent" vs. "other" (very good, good, fair, and poor). Using multivariate logistic regression, the association between overall satisfaction and the individual item problem scores that compose the Family Evaluation of Hospice Care were examined. Bereaved family members were more likely to rate overall satisfaction with hospice services as "excellent" if they were regularly informed about their loved one's condition (adjusted odds ratio [AOR]=3.76, 95% confidence interval [CI]=3.61-3.91), they felt the hospice team provided the right amount of emotional support to them (AOR=2.21, 95% CI=2.07-2.38), they felt that the hospice team provided them with accurate information about the patient's medical treatment (AOR=2.16, 95% CI=2.06-2.27), and they could identify one nurse as being in charge of their loved one's care (AOR=2.02, CI=1.92-2.13). These four key processes of care appear to significantly influence an "excellent" rating of overall satisfaction with hospice care.