Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue

Embracing Endings: Unveiling the Connection Between Final Conversations, the Opportunity Model for Presence, and Coping With the Death of Our Parents

This study examines adult children's loss of a parent through final conversations and communal coping. By looking at survivors' experiences through the lens of the opportunity model for presence (OMP) during the end-of-life (EOL) process, a model that provides a path of engagement leading to a good or bad death and consequent bereavement processes, we quantitatively test the relationships between two communication constructs before and after death of a parent. While final conversations as one construct did not lead to appraisal or action coping, results illustrate that final conversation topics of identity, instrumental, love, and everyday talk, were significantly related to shared appraisal. Instrumental talk and love were significantly related to joint action. Joint action and shared appraisal together led to participants engaging in all three types of coping. Final conversations as a whole, was important for bereavement outcomes, whereas communal coping's role in these relationships was convoluted.

Nursing students' perceptions of a good death: A mixed method study

BACKGROUND

Social aging tendencies and increasing chronic disease burdens draw people's attention to the concept of a good death.

OBJECTIVE

This study investigated how Chinese nursing students perceive a good death.

DESIGN

A mixed quantitative and qualitative design.

PARTICIPANTS AND SETTING

Four hundred and ninety-three nursing students from one mainland China university and one Macao SAR university participated in the study.

METHODS

The Good Death Inventory (Chinese version) was used to collect quantitative data. Qualitative data was collected through semi-structured interviews. Four hundred seventy-two questionnaires were collected, and 21 participants were interviewed. Quantitative and qualitative data were analyzed through statistics and thematic analysis, respectively.

RESULTS

Chinese nursing students gained an average score of 3.76 ± 0.39 in GDI-C. Students from mainland China, female, and with senior grades scored higher in the GDI-C (p < 0.05). Students' good death perception comprised four themes: positive psychological status, no physical suffering, open and supportive social surroundings, and spiritual/religious perfection. Mainland China and Macao students showed high consistency in their ranking of good death dimensions. The first five rankings in GDI-C were domains of being respected as an individual, dying in a favorite place, preparation for death, good relationships with family/medical staff, and environmental comfort. The last five rankings in GDI-C were domains of religious and spiritual comfort, independence, unawareness of death, pride and beauty, and not being a burden to others.

CONCLUSION

Chinese nursing students had a moderate degree of good death perception, characterized by the emphasis on social domains. Nursing students from mainland China and Macao SAR shared a similar perception of a good death in the Chinese context. More hospice care opportunities should be provided to students to train their empathy. Educators should guide students to apply principles of respect/dignity and open communication in the nursing practice.

Narrating Final Memories From Spousal Loss: The Role of Place and Quality of Death

Objective: Personal memories of the death of a spouse can guide bereavement adjustment. Place of death and quality of death are end-of-life factors that are likely to influence death experiences and formation of subsequent personal memories. The current study employs narrative content-analysis to examine how place and quality of death relate to affective sequences present in older adults' final memories from the death of their spouse. Method: Based on power analyses, 53 older adults were recruited and completed a Final Memory Interview. They also reported place of spouse's death (ie, in hospital, out of hospital) and quality of death across four subscales. Final memory narratives were reliably content-analyzed (interrater agreements >.70), revealing positive and negative affective sequences, including: redemption, contamination, positive stability, and negative stability. Findings: Experiencing the death of a spouse in hospital was related to narrating final memories with contamination. In terms of quality of death, reporting a less comforting social environment at time of death was related to the presence of redemption in final memories. Reporting that one's spouse received appropriate medical care related to narrating memories that showed positive stability. Conclusions: Final memories are carried with the bereaved long after their loss. Positive final memories appear to stem from witnessing a comfortable, medically appropriate death outside of a hospital setting. End-of-life 'that is' between care and aligned with patients' values for place and treatment may be critical for spouses' formation of constructive final memories and bereavement adjustment.

Older Adults' Perspectives on Voluntary Assisted Death: An In-Depth Qualitative Investigation in Australia

Interest in voluntary assisted death (VAD) has been growing among researchers, policy makers and the public. This study aimed to explore older adults' perspectives on VAD in Australia. Using purposive sampling, 15 adults ≥65 years participated in in-depth semi-structured interviews. Interpretative phenomenological analysis identified four themes: cultural reflections; beliefs and worldviews; health aspects; and fabric of life. Participants expressed a desire to have control over end-of-life options, challenged by religious beliefs. Participants expressed concern that VAD legislation could leave people vulnerable to coercion and saw a need for safeguards. Reasons for and against supporting and utilising VAD were discussed. Physical illness was seen a more compelling reason for VAD than mental ill-health. Finally, connections to life and other were discussed, and being able to do the things one loved were named aspects of what it meant to live a good life. Implications are discussed along with future research directions.

Intensive Care Nurses' Anxiety About COVID-19, Approaches to and Attitudes Toward Dying with Dignity Principles During the Pandemic

While trying to protect themselves from COVID-19, intensive care nurses saved many patients by providing care during the pandemic. The aim of this study is to determine the anxiety levels of nurses working in intensive care units about COVID-19, attitudes toward and approaches to end-of-life care, and attitudes toward dying with dignity. This cross-sectional descriptive study was carried out with 144 nurses. The Attitudes and Behaviors of ICU Nurses Intended for End-of-Life Care Scale, Attitudes towards Principles about Dying with Dignity Scale and COVID-19 Anxiety Scale were used to collect data. The mean age of the nurses was 30.02 ± 6.02. 63.80% of them were women and 62.20% of them worked in the internal intensive care unit. While the participants supported the principles of dying with dignity, their attitudes and approach to end-of-life care were at a good level, and COVID-19 anxiety was at a low level. Participants mostly adopted the protection of human dignity and privacy principles. Attitudes and approaches to end-of-life care and attitudes toward dying with dignity were not affected by COVID-19 anxiety.

Bereaved family members' perspectives on quality of death in deceased acute cardiovascular disease patients compared with cancer patients - a comparison of the J-HOPE3 study and the quality of palliative care in heart disease (Q-PACH) study

BACKGROUND

Outcome measures during acute cardiovascular disease (CVD) phases, such as quality of death, have not been thoroughly evaluated. This is the first study that compared the family members' perceptions of quality of death in deceased CVD patients and in deceased cancer patients using a bereaved family survey.

METHODS

Retrospectively sent questionnaire to consecutive family members of deceased patients with CVD from ten tertiary hospitals from October 2017 to August 2018. We used the short version of the Good Death Inventory (GDI) and assessed overall care satisfaction. Referencing the GDI, the quality of death was compared between CVD patients admitted to a non-palliative care unit (non-PCU) and cancer patients in palliative care units (PCU) and non-PCUs in the Japan Hospice and Palliative Care Evaluation Study (J-HOPE Study). Additionally, in the adjusted analysis, multivariable linear regression was performed for total GDI score adjusted by the patient and participant characteristics to estimate the difference between CVD and other patients.

RESULTS

Of the 243 bereaved family responses in agreement (response rate: 58.7%) for CVD patients, deceased patients comprised 133 (54.7%) men who were 80.2 ± 12.2 years old on admission. The GDI score among CVD patients (75.0 ± 15.7) was lower (worse) than that of cancer patients in the PCUs (80.2 ± 14.3), but higher than in non-PCUs (74.4 ± 15.2). After adjustment, the total GDI score for CVD patients was 7.10 points lower [95% CI: 5.22-8.97] than for cancer patients in PCUs and showed no significant differences compared with those in non-PCUs (estimates, 1.62; 95% CI [-0.46 to 5.22]).

CONCLUSIONS

The quality of death perceived by bereaved family members among deceased acute CVD patients did not differ significantly from that of deceased cancer patients in general wards, however, was significantly lower than that of deceased cancer patients admitted in PCUs.

Pain prevalence and pain relief in end-of-life care - a national registry study

BACKGROUND

Despite pain control being a top priority in end-of-life care, pain continues to be a troublesome symptom and comprehensive data on pain prevalence and pain relief in patients with different diagnoses are scarce.

METHODS

The Swedish Register of Palliative Care (SRPC) was used to retrieve data from 2011 to 2022 about pain during the last week of life. Data were collected regarding occurrence of pain, whether pain was relieved and occurrence of severe pain, to examine if pain differed between patients with cancer, heart failure, chronic obstructive pulmonary disease (COPD) and dementia. Binary logistic regression models adjusted for sex and age were used.

RESULTS

A total of 315 000 patients were included in the study. Pain during the last week of life was more commonly seen in cancer (81%) than in dementia (69%), heart failure (68%) or COPD (57%), also when controlled for age and sex, p < 0.001. Severe forms of pain were registered in 35% in patients with cancer, and in 17-21% in non-cancer patients. Complete pain relief (regardless of pain intensity) was achieved in 73-87% of those who experienced pain, depending on diagnosis. The proportion of patients with complete or partial pain relief was 99.8% for the whole group.

CONCLUSIONS

The occurrence of pain, including severe pain, was less common in patients with heart failure, COPD or dementia, compared to patients with cancer. Compared with cancer, pain was more often fully relieved for patients with dementia, but less often in heart failure and COPD. As severe pain was seen in about a third of the cancer patients, the study still underlines the need for better pain management in the imminently dying.

TRIAL REGISTRATION

No trial registration was made as all patients were deceased and all data were retrieved from The Swedish Register of Palliative Care database.

Good Death and Quality of End-of-Life Care in Patients with Coexisting Cancer and Dementia: Perspective of Bereaved Families

Background

Patients with coexisting cancer and dementia often have complex health care needs and face challenges in achieving a good death.

Objectives

To evaluate good death achievement and end-of-life (EOL) care in patients with coexisting cancer and dementia from the perspective of bereaved families.

Design

Cross-sectional nationwide postal survey.

Setting/Subjects

Bereaved families of patients with cancer who died in hospice and palliative care units across Japan.

Measurements

Bereaved families completed an anonymous, self-reported questionnaire. Their perspective on achieving a good death was assessed using the Good Death Inventory (GDI) (total score: 18-126). The Revised Care Evaluation Scale-short version (CES2) was used to assess EOL care (total score: 10-60). We examined the Brief Grief Questionnaire (BGQ) (total score: 0-10) and Patient Health Questionnaire 9 (PHQ9) (total score: 0-27).

Results

Data from 670 participants were analyzed, including 83 (12.4%) bereaved families of patients with coexisting cancer and dementia. No statistical differences were observed in the total GDI score for 18 items (dementia comorbidity vs. nondementia comorbidity groups, mean ± standard deviation, respectively, 78.4 ± 17.7 vs. 80.0 ± 15.5, adjusted [adj] P = 0.186), CES2 score (49.70 ± 9.22 vs. 48.82 ± 8.40, adj P = 0.316), BGQ score (3.40 ± 2.41 vs. 4.36 ± 2.28, adj P = 0.060), and PHQ9 score (4.67 ± 4.71 vs. 5.50 ± 5.37, adj P = 0.788).

Conclusions

GDI, CES2, BGQ, and PHQ9 scores did not differ significantly between groups, regardless of the presence of dementia in hospice and palliative care units. Patients with coexisting cancer and dementia can achieve a good death by high-quality EOL care.

Places of Farewell: A Scoping Review Exploring Factors Influencing the Choice of Place of Death for Children when Death is Expected

Progression of ill health and death trajectories is different for children with a non-oncology diagnosis. As previous research has focused primarily on children with cancer diagnoses, this scoping review explored what factors influence the parent and/or child's choice of place of death for a child with a non-oncological complex care condition, when death is expected. Eighteen papers were identified considering the preferred place of death. The findings were themed into 1. Diagnostic Factors; 2. Home Factors; 3. Socio-economic Factors; 4. Parent Factors. In conclusion, informed discussions with families that recognize the reason for, and the impact of their choices, are necessary not only for the preferred place of death but also end of life care.

Experiences of Isolation among Patients Hospitalized during an Infectious Disease Outbreak: A Systematic Review and Meta-Ethnography

Hospital isolation is common for people during infectious disease outbreaks. Anxiety, stress, depression and other psychosocial outcomes have been reported due to these measures. However, there is scarce evidence about the experience of being isolated and about best practices for empathic clinical care in these circumstances. The aim of this study was to explore the experience of isolation on patients hospitalized during an infectious disease outbreak. A systematic review and meta-ethnography was carried out. A search strategy was applied to the PubMed, CINAHL, Web of Science, and PsycINFO databases on April 14, 2021 and again May 2, 2022. Data synthesis was conducted using Noblit and Hare's method of qualitative thematic synthesis. Twenty reports were included in this review: 16 qualitative, two mixed-methods (only the qualitative part was analyzed), plus 2 personal view pieces. They described the experiences of a total of 337 people hospitalized and isolated with an infectious disease. Following analysis and coding of data, four themes emerged: 1) Feelings triggered by isolation; 2) Coping strategies; 3) Connection/disconnection; 4) Factors that influence the experience of isolation. Despite a sensitive search strategy, limited studies represent patient experiences using qualitative methods. The experience of isolation among patients hospitalized during an outbreak is characterized by fear, perceived stigma, and a sense of disconnection from others and the outside world due to a lack of information. Fostering a person-centered care model could help hospitalized patients develop adaptive mechanisms that minimize the impact of isolation.

Older adults' attitudes toward using Euthanasia at the end-of life: cancer vs. Parkinson's disease

Background

There is a paucity of studies that compare older adults' attitudes toward Euthanasia in two different terminal illnesses. Moreover, these studies did not relate to potentially influencing psycho-social factors. The current study aimed to examine the impact of a diverse range of variables on attitudes among older adults toward Euthanasia in two medical conditions: cancer and Parkinson's disease.

Methods

A total of 501 individuals aged 75 and above participated in the study. Attitudes toward Euthanasia were measured using vignettes which described two conditions: an 80-year-old man with metastatic cancer and another man in an advanced stage of Parkinson's disease. The questionnaire included measures of relevant experience (with a close family member or a friend dying from a terminal illness), self-efficacy, will to live, satisfaction with life, will to prolong life, fear of death and dying, social support, and psycho-social characteristics. The data were analyzed using hierarchical linear regression models.

Results

A more positive attitude toward Euthanasia was found in the case of cancer compared to Parkinson's disease. Being a woman, having more years of education, lower level of religiosity, greater fear of death and dying and higher self-efficacy contributes to more favorable attitudes toward Euthanasia in both end-of life conditions.

Conclusions

The finding that attitudes toward Euthanasia are statistically significantly more positive in the case of cancer compared to Parkinson's disease can be attributed to the greater prevalence of cancer in the population, and to the public's awareness of the suffering associated with each of these medical conditions. Beyond the important role of the socio-demographic characteristics of gender, education, and religiosity, it appears that fear of death and dying and self-efficacy are important psychological factors in explaining attitudes toward Euthanasia in both illnesses among older people. These findings shed light on older adults' attitudes toward Euthanasia in debilitating illnesses.

End of life and death of residents: Experiences and practices of care facility directors in Portuguese residential care facilities

Residential care facilities (RCFs) are places where older people live and usually die. This exploratory qualitative study aims to describe the experiences and practices of the directors of Portuguese RCFs regarding residents' end of life and death. Data were obtained from 17 care facility directors (CFDs) who participated in three focus groups. Thematic data analysis was performed. The CFDs described their practices and experiences framed within three moments in the life journey of the residents in RCFs: admission and living in RCF; end of life and death; postmortem and new admission - continuing and occupying the vacancy. The results suggest that end of life and death are only addressed in the last days/hours of life of the resident. However, the CFDs' approach throughout the stay of the residents in the RCF could allow for the expression of their wishes and wills, which could facilitate a good and dignified death.

Fearing Pain at the End of Life: A Review of Advance Directives

BACKGROUND

Patients, caregivers, and healthcare professionals often describe a "good death" as a pain-free process. However, many patients experience pain during their last weeks of life. Advance directives (ADs) are legally binding documents that allow individuals to express their wishes for end-of-life care which should include management of their pain.

METHODS

An interprofessional team conducted a comprehensive analysis of ADs from all 50 states and the District of Columbia to assess the inclusion of language that reflects patients' wishes for pain relief at the end of life.

RESULTS

Thirty-seven (73%) of the 51 entities examined reflected the prototypical directive, containing explicit instructions for withholding or withdrawing interventions that may prolong suffering rather than options for treating pain. Of these, 12 (24%) did not include the word "pain". Only 14 states (27%) provided clear guidance for managing pain. Unexpectantly, researchers found that 13 (25%) addressed the common fears of patients, caregivers, and healthcare teams when using opioids to relieve suffering, such as addiction, sedation, appetite, or respiratory suppression, and hastening death.

CONCLUSION

The majority of ADs reviewed lacked clear and comprehensive measures for addressing pain relief. This deficiency may contribute to the undertreatment of pain and amplify the anxiety felt by patients, families, and healthcare providers when making end-of-life decisions. The results highlight the need for improvements in ADs to help ensure that patients' wishes regarding pain management are adequately addressed, documented and respected.

[Human dignity and autonomy in medicoethical decisions at the end of life]

Respect of human dignity is an unquestionable part of daily clinical routine as well as of evaluations in medical ethics. Some aspects of human dignity are a subject of transformation in the course of a lifetime. If the ability to form a will is reduced, it might be difficult to satisfy the individual perception of a dignified treatment, which is of particular interest in terminal care. As illustrated by the presented case report, moral problems can arise when the patient's present verbal or non-verbal expressions are opposed to what is documented or what is estimated by dependants to be the individual's will. In clinical decision-making processes, the determination of the will via an advance directive can be overstated, which can go so far that human dignity is reduced to autonomy. A concept of dignity reduced to autonomy misses the point not only of a dignity-centered medical care but also of shared decision-making. In situations at the end of life other aspects, such as authenticity or self-actualization should be considered when respecting the individual's dignity. Medicine should as such not marginalize death but provide a care based on principles that focus on human interaction and respect for a comprehensive concept of dignity.

Associations between the spread of COVID-19 and end-of-life circumstances in the non-infected population of Sweden

AIMS

Since its outbreak in 2020, the COVID-19 pandemic has directly caused the premature death of millions. However, indirect consequences, such as social restrictions, have affected a far greater number. We explored the association between the spread of COVID-19 and end-of-life circumstances in the infected and non-infected population in Sweden.

METHODS

In this descriptive, population-based, observational study, we primarily used data from the Swedish National Registry of Palliative Care, which covers about 60% of all deaths in Sweden. We explored the association between the spread of COVID-19 and place of death, people present at death and end-of-life symptoms using regression analyses.

RESULTS

The study included 190,291 individuals who died in any region of Sweden from 1 January 2019 to 30 June 2022, of which 10,646 were COVID-19 cases. Correlated to the temporal and geographical spread of COVID-19, there was a greater proportion of individuals dying without the presence of their next-of-kin, and consequently more people dying alone, both in those with and without COVID-19. There was a similar pattern of a greater proportion of deaths taking place in nursing homes and in the individual's own home. However, we did not find substantial associations to reported symptoms, such as anxiety or confusion.

CONCLUSIONS

This study shows the profound effects of the COVID-19 pandemic on end-of-life circumstances in both the infected and non-infected population in Sweden. As we prepare for future pandemics, there is a need to develop strategies to minimise the impact on non-infected individuals.

Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

Background and aim

While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored.

Methods

There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes.

Results

About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC.

Conclusion

Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.

How to cite this article

Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.

Prolonged grief in relatives of deceased patients due to COVID-19 is associated with anxiety and depressive symptoms: A survey-based study in Peru

Objective

Funeral practices have undergone significant changes during the COVID-19 pandemic. Thus, the death of a family member from this disease has altered the typical course of the bereavement process. Therefore, this study seeks to determine the relationship between the levels of grief, anxiety, and depression in relatives of patients who died from COVID-19 in Peru.

Methods

A total of 250 volunteers were obtained, but after applying the inclusion criteria and not being able to contact five of them, the sample consisted of 115 participants over 18 years of age who lost a family member to COVID-19 between 2020 and 2021. They developed the Prolonged Grief Questionnaire-13 and the Zung Anxiety and Depression Questionnaires, in virtual surveys using Google FormTM (Google, CA).

Results

Our analysis revealed that all cases of anxiety (18.3%) were present in individuals experiencing prolonged grief (76.5%), while 49.5% (57/115) of participants exhibited symptoms of depression. Furthermore, we identified a significant association between prolonged grief and both anxiety (p = 0.005) and depression (p < 0.001). Prolonged grief predominantly affected females (45.2%) and individuals aged 31-40 years (28.7%) (p < 0.001). Regarding predictors of anxiety symptoms, we found that both age group (p = 0.035) and grief (p < 0.001) played significant roles. Gender (p = 0.019) and grief (p < 0.001) emerged as predictors of depression, while gender alone predicted grief in relatives of individuals who succumbed to COVID-19 (p = 0.019).

Conclusion

Our results suggest a clear association between prolonged grief and mental health issues among relatives of COVID-19 patients who have passed away. Consequently, it is imperative to provide comprehensive psychological and spiritual support throughout the grieving process, aiming to mitigate the negative impact of traumatic events.

"People aren't happy to see refugees coming to Switzerland. They don't like assisted suicide for foreigners": Organizations' perspectives regarding the right-to-die and suicide tourism

The practice of suicide tourism refers to the traveling of individuals to other countries to seek legally permitted assisted suicide. This study employed a descriptive qualitative research approach exploring how right-to-die organizations perceive suicide tourism and its implications on the right-to-die. Five themes emerged following the analysis of 12 in-depth interviews with activists from right-to-die organizations and 13 relevant documents: (1) unequivocal attitudes toward suicide tourism; (2) relationships between the organizations and the media; (3) acting to change the legal status of the right-to-die; (4) the role of the family in interactions between the organization and the person seeking assistance; and (5) reciprocal relations between the organizations and the physicians. The findings reveal ambivalent attitudes within such organizations toward suicide tourism, inherent tension among participating physicians, and complex relationships between assisted suicide, palliative care, and the physicians' duty to promote individual choice at end-of-life.

Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

Exploring the occurrence and the risk factors of the desire for hastened death and depression in people with early-stage dementia in Greece

OBJECTIVES

To assess the factors associated with desire for hastened death and depression in early-stage dementia as well as the association between them. Also, to explore the mediator and moderator role of age in the relationship between depression and desire for hasten death.

METHODS

A prospective cross-sectional study including 100 patients diagnosed with early-stage dementia from a rehabilitation center between December 2018 and July 2019. Measurement tools used were the Mini-Mental State Examination, the Greek Montreal Cognitive Assessment, the Greek Schedule of Attitudes toward Hastened Death, and the Geriatric Depression Scale-15 item. Patients diagnosed with dementia as a result of Stroke history were excluded.

RESULTS

Factors of multifactorial analysis significantly associated with desire for hastened death were as follows: age (p = 0.009), marital status (p = 0.001), and depression (p < 0.001). The factor significantly associated with depression was age (p = 0.001). Also, a mediation/moderation analysis has shown that depression and age are significant predictors of desire for hasten death.

SIGNIFICANCE OF RESULTS

The desire for hastened death and depression in people diagnosed with early-stage dementia includes many components. Younger patients, men, higher educated patients, single, childless, and those with higher depression scores had higher desire for hastened death, while men and older patients had higher scores of desire for depression. Our study provides important information about the desire for hastened death and depression in early-stage dementia, their risk factors, and their association.

Community perspectives on structural barriers to dying well at home in Canada

OBJECTIVES

To analyze how structural determinants and barriers within social systems shape options for dying well at home in Canada, while also shaping preferences for dying at home.

METHODS

To inform a descriptive thematic analysis, 24 Canadian stakeholders were interviewed about their views, experiences, and preferences about dying at home. Participants included compassionate community advocates, palliative care professionals, volunteers, bereaved family caregivers, residents of rural and remote regions, service providers working with structurally vulnerable populations, and members of francophone, immigrant, and 2SLGBTQ+ communities.

RESULTS

Analysis of stakeholders' insights and experiences led to the conceptualization of several structural barriers to dying well at home: inaccessible public and community infrastructure and services, a structural gap in death literacy, social stigma and discrimination, and limited access to relational social capital.

SIGNIFICANCE OF RESULTS

Aging in Canada, as elsewhere across the globe, has increased demand for palliative care and support, especially in the home. Support for people wishing to die at home is a key public health issue. However, while Canadian policy documents normalize dying in place as ideal, it is uncertain whether these fit with the real possibilities for people nearing the end of life. Our analysis extends existing research on health equity in palliative and end-of-life care beyond a focus on service provision. Results of this analysis identify the need to expand policymakers' structural imaginations about what it means to die well at home in Canada.

A Systematic Scoping Review on Dignity Assessment Tools

CONTEXT

The provision of person-centered dignity-conserving care is central to palliative care. It is important to reevaluate current methods of assessing dignity as the concept of dignity is multifaceted.

OBJECTIVES

The aim of this study is to understand the tools which are used to assess a patient's dignity and the elements of dignity evaluated in these tools.

METHODS

Two independent and concurrent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA) on existing dignity assessment tools and on accounts of assessments of dignity were carried out. The SSR in SEBA on dignity assessment tools involving PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, and CINAHL databases saw 22 full-text articles included from the 645 articles reviewed. The SSR in SEBA on accounts of assessments of dignity featured in the PubMed database identified 102 full-text articles which saw 46 articles included.

RESULTS

The domains identified were factors affecting patients' definition of dignity; elements of dignity-conserving care; and components of effective tools.

CONCLUSION

Current accounts to assess dignity and assessment tools fail to capture shifting self-concepts of dignity holistically. A portfolio-like appraisal of dignity is proposed to achieve assessments that are timely, longitudinal, and patient-specific. Portfolio-based assessments by members of the multidisciplinary team will better direct timely evaluations of relevant aspects of changing concepts of dignity, without losing the patient's holistic perception of dignity.

Health Care Access Dimensions and Racial Disparities in End-of-Life Care Quality among Patients with Ovarian Cancer

This study investigated the association between health care access (HCA) dimensions and racial disparities in end-of-life (EOL) care quality among non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic patients with ovarian cancer. This retrospective cohort study used the Surveillance, Epidemiology, and End Results-linked Medicare data for women diagnosed with ovarian cancer from 2008 to 2015, ages 65 years and older. Health care affordability, accessibility, and availability measures were assessed at the census tract or regional levels, and associations between these measures and quality of EOL care were examined using multivariable-adjusted regression models, as appropriate. The final sample included 4,646 women [mean age (SD), 77.5 (7.0) years]; 87.4% NHW, 6.9% NHB, and 5.7% Hispanic. In the multivariable-adjusted models, affordability was associated with a decreased risk of intensive care unit stay [adjusted relative risk (aRR) 0.90, 95% confidence interval (CI): 0.83-0.98] and in-hospital death (aRR 0.91, 95% CI: 0.84-0.98). After adjustment for HCA dimensions, NHB patients had lower-quality EOL care compared with NHW patients, defined as: increased risk of hospitalization in the last 30 days of life (aRR 1.16, 95% CI: 1.03-1.30), no hospice care (aRR 1.23, 95% CI: 1.04-1.44), in-hospital death (aRR 1.27, 95% CI: 1.03-1.57), and higher counts of poor-quality EOL care outcomes (count ratio:1.19, 95% CI: 1.04-1.36). HCA dimensions were strong predictors of EOL care quality; however, racial disparities persisted, suggesting that additional drivers of these disparities remain to be identified.

SIGNIFICANCE

Among patients with ovarian cancer, Black patients had lower-quality EOL care, even after adjusting for three structural barriers to HCA, namely affordability, availability, and accessibility. This suggests an important need to investigate the roles of yet unexplored barriers to HCA such as accommodation and acceptability, as drivers of poor-quality EOL care among Black patients with ovarian cancer.

The Health Service Model for Promoting Good Death in Critically Ill End-of-Life Patients in the Emergency Department: A Qualitative Study

Good death is one of the important outcomes of end-of-life care service delivery. The initial management of critically ill patients in the Emergency Department (ED) for promoting good death often challenging since it requires a focus on human dignity and equity at the end of life. A qualitative approach was used included eight bereaved family members who loss of their loved one in the ED and 25 emergency staff, including 11 emergency physicians and 14 emergency nurses of a super tertiary hospital in Thailand. Semi-structured, face-to-face interviews were conducted from February to August 2021. All the interviews were transcribed verbatim for content analysis. The result identified four distinct scenarios and seven core themes of end-of-life patient characteristics in the ED. To promote a good death in the ED, health care provider should consider the unique service deliver for each critically end-of-life patients and their family members.

Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study

BACKGROUND

In the intensive care unit (ICU), we may encounter patients who have completed a Do-Not-Resuscitate (DNR) or a Physician Orders to Stop Life-Sustaining Treatment (POLST) document. However, the characteristics of ICU patients who choose DNR/POLST are not well understood.

METHODS

We retrospectively analyzed the electronic medical records of 577 patients admitted to a medical ICU from October 2019 to November 2020, focusing on the characteristics of patients according to whether they completed DNR/POLST documents. Patients were categorized into DNR/POLST group and no DNR/POLST group according to whether they completed DNR/POLST documents, and logistic regression analysis was used to evaluate factors influencing DNR/POLST document completion.

RESULTS

A total of 577 patients were admitted to the ICU. Of these, 211 patients (36.6%) had DNR or POLST records. DNR and/or POLST were completed prior to ICU admission in 48 (22.7%) patients. The DNR/POLST group was older (72.9 ± 13.5 vs. 67.6 ± 13.8 years, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (26.1 ± 9.2 vs. 20.3 ± 7.7, p < 0.001) and clinical frailty scale (5.1 ± 1.4 vs. 4.4 ± 1.4, p < 0.001) than the other groups. Solid tumors, hematologic malignancies, and chronic lung disease were the most common comorbidities in the DNR/POLST groups. The DNR/POLST group had higher ICU and in-hospital mortality and more invasive treatments (arterial line, central line, renal replacement therapy, invasive mechanical ventilation) than the other groups. Body mass index, APAHCE II score, hematologic malignancy, DNR/POLST were factors associated with in-hospital mortality.

CONCLUSIONS

Among ICU patients, 36.6% had DNR or POLST orders and received more invasive treatments. This is contrary to the common belief that DNR/POLST patients would receive less invasive treatment and underscores the need to better understand and include end-of-life care as an important ongoing aspect of patient care, along with communication with patients and families.

The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective

BACKGROUND

Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population.

AIM

To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives.

METHODS

A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach.

RESULTS

Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith.

CONCLUSION

Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.

In-hospital end-of-life care: an appreciative analysis of bereaved family feedback

Experience feedback data is increasingly recognised as being helpful in improving healthcare services, and in meeting patient and family needs. This end-of-life care project, based on the principles of appreciative inquiry, sought to learn from the experiences of bereaved people whose relative had died in an acute hospital setting. Informal feedback, offered during a routine telephone call, was thematically analysed and interpreted in an appreciative manner. Confirmatory representations of caring practices and behaviours were identified, categorised and disseminated in a way that enabled staff to come to know and understand end-of-life care at its best, rather than as a set of problematised events. The findings served as a benchmark for individuals and teams to assess and progress their practice reflectively. The authors conclude that staff receptiveness to informal bereaved family feedback may be enhanced by focusing on the positive qualities of end-of-life care within existing practices.

Attitudes and experiences related to the deaths of COVID-19 patients among nursing staff: A qualitative evidence synthesis

AIM

To identify and synthesize the experiences and attitudes of nursing staff regarding the deaths of COVID-19 patients.

REVIEW METHODS

A qualitative evidence synthesis was carried out, using Noblit and Hare's meta-ethnographic approach. The review protocol was listed in PROSPERO (CRD42022330928). Studies published from January 2020 to January 2022 that met the criteria were searched in PubMed, Web of Science, Scopus, CINAHL, CUIDEN and PsycInfo. A total of 12 articles were included.

RESULTS

Thirty-three metaphors emerged, which were grouped into three main themes: Determining factors of care, Feelings about death and Strategies for coping with death. Nurses reported the high emotional toll, the absence of family and the lack of staff, protocol and training as determining factors. Furthermore, staff had doubts about the quality of care that COVID-19 patients received. As coping strategies, nurses developed avoidance behaviours towards COVID-19 patients, selective memories, resilience, and/or leaving the profession.

CONCLUSIONS

The difficulty in providing adequate nursing care and the high number of deaths has increased anxiety and stress among nurses. These factors, alongside their lived experiences of seeing patients suffering, many dying alone without family members, have had psychological repercussions on nursing staff.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results demonstrate a high emotional toll and doubts surrounding their caregiving role caused by the lack of professional training needed to face a pandemic. This research shows what has been learned for future pandemics and highlights basic components that could provide a foundation for coping interventions for healthcare professionals.

IMPACT

WHAT PROBLEM DID THE STUDY ADDRESS?: The challenges posed by COVID-19 patient deaths for nursing staff around the world and also by the pandemic circumstances in which those deaths occurred. WHAT WERE THE MAIN FINDINGS?: The high number of deceased patients who were isolated from family members, communication with family members and doubts surrounding care given during the pandemic have created feelings of fear, stress and anxiety, as well as obsessive thoughts that have changed nursing staff's perception of death due to COVID-19. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Results will be useful for preparing for future pandemics, and for policymakers and health staff in supporting healthcare professionals by creating programmes to help them cope with the emotional toll they have felt after dealing with death in such unprecedented circumstances.

REPORTING METHOD

The authors have adhered to the PRISMA guidelines and the eMERGe Reporting Guidance.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Attitudes of Oncology Nurses Towards Care of Dying Patients and the Principles of Dying with Dignity and Their Views on Good Death

This study investigated oncology nurses' attitudes toward caring for dying patients, their principles of dying with dignity, and their views on good death. This descriptive study included 257 oncology nurses working at two university hospitals, an educational research hospital and a state hospital in Turkey. Data were collected using the descriptive characteristics information form, the Frommelt Attitudes toward Care of the Dying scale, the Assessment Scale of Attitudes toward the Principles of Dying with Dignity, and the Good Death Scale. The nurses obtained mean scores of 99.53 ± 7.76 on the Frommelt Attitudes toward Care of the Dying scale, 26.84 ± 12.45 on the Assessment Scale of Attitudes toward the Principles of Dying with Dignity, and 57.23 ± 7.48 on the Good Death Scale. The nurses' personal and professional characteristics influenced their attitudes toward caring for dying patients, the principles of dying with dignity, and their views on good death.

Spiritual-Cultural Needs as the Main Causative Factor of Death Anxiety in Iranian COVID-19 Patients: A Qualitative Study

COVID-19 patients have been reported to more than likely experience a variety of difficult physical and psychological problems. This qualitative study aims to perceive psychological experiences in COVID-19 patients in Iran. The study method is qualitative, with a conventional content analysis approach adopted. Purposive sampling was applied to 20 COVID-19 patients admitted to medical wards at hospitals in Tehran, Iran. Additionally, data were collected using semi-structured interviews. All data were analyzed based on the method proposed by Lindgren et al. (Int J Nurs Stud 108:103632, 2020). Data analysis identified the main theme to be "death fear and anxiety" with five main categories. These categories included the feelings of death panic and apprehension, uncertainty and ambiguity, fear of abandonment, fear of an unknown future for the family, and fear of unmet spiritual-cultural needs. Accordingly, the patients' experiences of COVID-19 contraction were unique. Against this backdrop, understanding COVID-19 patients' complexities, experiences, beliefs, and attitudes about anxiety and death, can lead to an  improved awareness and understanding of the psychological consequences of COVID-19 by executive decision-makers, healthcare personnel and mental health professionals.

Psychological well-being of hospice staff: systematic review

BACKGROUND

Poor psychological well-being among healthcare staff has implications for staff sickness and absence rates, and impacts on the quality, cost and safety of patient care. Although numerous studies have explored the well-being of hospice staff, study findings vary and the evidence has not yet been reviewed and synthesised. Using job demands-resources (JD-R) theory, this review aimed to investigate what factors are associated with the well-being of hospice staff.

METHODS

We searched MEDLINE, CINAHL and PsycINFO for peer-reviewed quantitative, qualitative or mixed-methods studies focused on understanding what contributes to the well-being of hospice staff who provide care to patients (adults and children). The date of the last search was 11 March 2022. Studies were published from 2000 onwards in the English language and conducted in Organisation for Economic Co-operation and Development countries. Study quality was assessed using the Mixed Methods Appraisal Tool. Data synthesis was conducted using a result-based convergent design, which involved an iterative, thematic approach of collating data into distinct factors and mapping these to the JD-R theory.

RESULTS

A total of 4016 unique records were screened by title and abstract, 115 full-text articles were retrieved and reviewed and 27 articles describing 23 studies were included in the review. The majority of the evidence came from studies of staff working with adult patients. Twenty-seven individual factors were identified in the included studies. There is a strong and moderate evidence that 21 of the 27 identified factors can influence hospice staff well-being. These 21 factors can be grouped into three categories: (1) those that are specific to the hospice environment and role, such as the complexity and diversity of the hospice role; (2) those that have been found to be associated with well-being in other similar settings, such as relationships with patients and their families; and (3) those that affect workers regardless of their role and work environment, that is, that are not unique to working in a healthcare role, such as workload and working relationships. There was strong evidence that neither staff demographic characteristics nor education level can influence well-being.

DISCUSSION

The factors identified in this review highlight the importance of assessing both positive and negative domains of experience to determine coping interventions. Hospice organisations should aim to offer a wide range of interventions to ensure their staff have access to something that works for them. These should involve continuing or commencing initiatives to protect the factors that make hospices good environments in which to work, as well as recognising that hospice staff are also subject to many of the same factors that affect psychological well-being in all work environments. Only two studies included in the review were set in children's hospices, suggesting that more research is needed in these settings.

PROSPERO REGISTRATION NUMBER

CRD42019136721 (Deviations from the protocol are noted in Table 8, Supplementary material).

Pain management in German hospices: a cross-sectional study

BACKGROUND AND OBJECTIVES

Pain management is a necessary component of palliative care as most patients suffer from pain during the final phase of life. Due to the complex causation of pain in the last phase of life, it is important to utilize methods other than pharmacotherapeutic options in order to achieve adequate pain control. As little is known about treatment of pain in German hospices, a nationwide survey was conducted.

MATERIALS AND METHODS

All German hospices (259) were contacted by post in June 2020 and asked to participate in an anonymous cross-sectional survey.

RESULTS

A total of 148 (57%) German hospices took part in the survey. A broad variety of medication is used in the hospice setting. Metamizole is the most commonly used non-opiod analgesic , hydromorphone the most commonly used opioid, and pregabalin is the most commonly prescribed co-analgesic drug. The pain medication is usually prescribed as an oral slow-release substance. Standardized treatment schemes are rare among the responding hospices. Most of the respondents also use complementary treatment options, such as aroma (oil) therapy or music therapy, in the treatment of pain. Palliative sedation is used by nearly all responding hospices if all other treatment options fail.

CONCLUSION

This survey provides an overview of the treatment options for pain management in German hospices. A broad variety of pain medication is used. Compared to international literature, it is debatable whether such a large variety of different types of pain medication is necessary, or whether a reduction in the type of medication available and the use of standardized treatment schemes could benefit everyone involved.

Cancer Pain Management in Patients Receiving Inpatient Specialized Palliative Care Services

CONTEXT

Cancer pain is a common complication that is frequently undertreated in patients with cancer.

OBJECTIVES

This study is aimed at assessing the time needed to achieve cancer pain management goals through specialized palliative care (SPC).

METHODS

This was a multicenter, prospective, longitudinal study of inpatients with cancer pain who received SPC. Patients were continuously followed up until they considered cancer pain management successful, and we estimated this duration using the Kaplan-Meier method. We investigated the effectiveness of pain management using multiple patient-reported outcomes (PROs) and quantitative measures, including pain intensity change in the Brief Pain Inventory. A paired-sample t-test was used to compare the pain intensity at the beginning and end of the observation period.

RESULTS

Cancer pain management based on the PROs was achieved in 87.9% (385/438) of all cases. In 94.5% (364/385) of these cases, cancer pain management was achieved within 1 week, and the median time to pain management was 3 days (95% confidence interval [CI], 2-3). The mean worst pain intensity in the last 24 h at the start and end of observation were 6.9 ± 2.2 and 4.0 ± 2.3, respectively, with a difference of -2.9 (95% CI, -3.2 to -2.6; p < 0.01). Overall, 81.6% of the patients reported satisfaction with cancer pain management, and 62 adverse events occurred.

CONCLUSION

SPC achieved cancer pain management over a short period with a high level of patient satisfaction resulting in significant pain reduction and few documented adverse events.

Nobody Should Die Alone. Loneliness and a Dignified Death During the COVID-19 Pandemic

During the direst months of the COVID-19 pandemic, thousands of people died alone. This study analyzes these deaths, which occurred without the presence of loved ones, and seeks to a) examine the significance for relatives, as well as professionals, of dying alone, b) determine if these solitary deaths can be considered dignified, or good deaths, and c) evaluate if the treatment of the cadavers and the funeral rites transpired with the desired dignity and sensitivity. The study was carried out in the autonomous community of Madrid using a qualitative, phenomenological, and interpretative approach through in-depth interviews of 49 informants, professionals and relatives. Interviews were conducted between July and November of 2020, followed by an interpretive, categorical, qualitative analysis. Among the key findings are that during the most critical months, deaths lacked the desired dignity, even though the involved professionals did their best to accompany and dignify the deaths.

A good death: non-negotiable personal conditions for clinicians, healthcare administrators and support staff

OBJECTIVES

To ask all clinical, administrative and support staff affiliated with a large network of healthcare facilities to identify the conditions that they consider as non-negotiable for their own deaths to be regarded as good.

METHODS

All 3495 staff of a healthcare network were asked to rank 10 conditions according to how non-negotiable they would be for themselves during their final 3 months or few hours for their own deaths to be considered as good. They were also asked about whether they had thought about their own death in the last 3 months, if they had a will, believed in God, and in the possibility of a good death, and the intensity of their fear of death.

RESULTS

2971 (85%) completed the survey. Most were female (79%) and clinical staff (65%). 93% believed in God, 60% had thought about their death recently, 33% had an intense fear of death, and 4% had a will. 64% considered a good death possible. Participants ranked dying at a preferred place, emotional support from family and friends and relief from physical symptoms as their top priorities. The lowest ranked conditions were (from the bottom) relief from psychological distress, performance of rituals and the right to terminate life. There were no statistically significant differences across genders or individual occupational groups.

CONCLUSION

Most of conditions for a good death of interest to healthcare professionals could be provided without sophisticated medical infrastructure or specialised knowledge, opening the door for new support services to make it possible for everyone, anywhere.

Patient safety and hospital visiting at the end of life during COVID-19 restrictions in Aotearoa New Zealand: a qualitative study

BACKGROUND

Visiting restrictions were enacted in Aotearoa New Zealand to reduce transmission of COVID-19 and protect the healthcare system. This research aimed to investigate the experiences of families and clinicians of hospital visiting for people with palliative and end-of-life care needs during restrictions.

METHODS

Semistructured interviews were completed between March and October 2021 with family members and clinicians who had personally experienced enactment of visiting restrictions during pandemic restrictions. A critical realist ontology was used to approach data analysis, sorting and coding to generate themes.

RESULTS

Twenty-seven participants were interviewed, 13 being families who had experienced bereavement of a family member during the restrictions: seven nurses or physicians and seven being non-bereaved family members. Four themes were generated: patient safety-(re)defining the 'Visitor'; the primacy of SARS-CoV-2-patient safety and negotiating risk; dying alone: enduring harms; and agency, strategies and workarounds.

CONCLUSION

Visitor rights and visitor policy at the end of life require greater protection during a pandemic. Transparent, coherent, publicly available evidence-based guidelines that key stakeholders, including patients, families and ethicists, are included in producing, are urgently required. We want to avert a legacy of disenfranchised grief in future pandemics.

What we learnt from parents' death experience: A cross-sectional study of death literacy and parent's death quality among adult children in China

OBJECTIVES

This study aims at investigating the current status of death literacy and parent's death quality among adult children in China. A cross-sectional survey was conducted to explore the associations between death literacy and parent's death quality and to provide evidence for developing public policies for improving the quality of death and end-of-life care for the population in the Greater Bay Area (GBA) of China.

METHODS

A cross-sectional design was adopted. Participants who experienced their father's and/or mother's death were recruited from 5 cities in the GBA of China in 2022. The Good Death Inventory (GDI) and the Death Literacy Index (DLI) were used to investigate the perceived quality of death of the parents of the participants and the death literacy of the participants.

RESULTS

A total of 511 participants were recruited. Participants with higher GDI scores were positively associated with DLI scores (p < 0.001). Adult children who had close relationships before their parents' death also had higher levels of DLI.

SIGNIFICANCE OF RESULTS

This study investigated death literacy among bereaved adult children in China, filling a gap in the investigation of death literacy among Chinese residents. It found that parents' death experience can have a significant impact on the death literacy of adult children, which may affect their understanding and preparation for their own eventual death. Promotion of family discussion on death, development of community palliative care, and improving public death literacy are urgently needed in China.

Experiences of engaging a death doula: qualitative interviews with bereaved family members

Background

There has been an emerging trend of adopting a death doula, a non-medical advocate and guide for people at the end of life and their families. While there has been growing empirical research regarding the work of death doulas, no studies have been undertaken with the families who have engaged them.

Objectives

To understand the experiences of families who used a death doula in terms of what they did for the patient and family; to understand the benefits and drawbacks of using a death doula; and to use family insight to determine cultural shifts towards death and dying, and what the death doula phenomenon tells us around our attitudes towards death and dying.

Methods

We recruited and interviewed 10 bereaved family members to learn about their experiences using a death doula. This qualitative research took an interpretive phenomenological approach, and thematic analysis was used to analyse the data.

Results

The most valuable attribute the families gained from death doulas was an increase in death literacy resulting in personal empowerment. Empowerment enabled positive end-of-life experiences for the family and personalised deaths for the patient. A novel finding was that the connections and knowledge shared between the death doula and family had a resonant effect, resulting in families being more comfortable with death and keen to share their knowledge with others. Therefore, family engagement of a death doula led to an increase in community awareness around death and dying.

Conclusion

Family members' experience with a death doula was overwhelmingly positive, empowering them practically and emotionally to deliver the best end-of-life care. Empathy and sharing of knowledge by death doulas were valued by families and resulted in an increase in death literacy which provided families with opportunities to 'pay it forward'. Furthermore, the relationships formed between doulas and families have the potential for a lasting, resonant effect.

Cultural adaptation and validation of the Quality of Dying in Long-term Care (QoD-LTC and QoD-LTC-C) scales by caregivers in nursing homes

BACKGROUND

There is a lack of tools that can evaluate quality of dying in nursing homes from the perspective of deceased patients' caregivers. The aim of this study was to adapt and validate the caregivers' versions of the Quality of Dying in Long-Term Care (QoD-LTC) and Quality of Dying in Long-Term Care Complete (QoD-LTC-C) scales in the Spanish context.

METHODS

This was a cultural adaptation and validation study. The scales were translated from English to Spanish and vice versa, and 13 experts in end-of-life care participated in a two-round Delphi panel. Caregivers of 69 deceased residents from seven nursing homes in southern Spain completed both scales. Reliability, feasibility, and concurrent validity with global quality of dying perception and symptom burden (Edmonton Symptom Assessment Scale), were evaluated.

RESULTS

Spanish caregivers' version of the QoD-LTC scale showed good internal consistency for the total scale (α = 0.74) and each of its three factors, and good inter-rater reliability (ICC = 0.50) and test-retest reliability (ICC = 0.81). The Spanish QoD-LTC-C scale for caregivers showed good internal consistency for the total scale (α = 0.81) and for its component factors, and good test-retest reliability (ICC = 0.89) and inter-rater reliability (ICC = 0.66). Both scales correlated with family caregivers' global perception of deceased residents' quality of dying (r = 0.39; r = 0.32), but not with the ESAS score.

CONCLUSIONS

Both scales presented an adequate factorial structure, internal consistency, and reliability to assess caregivers' perception of the quality of dying in Spanish nursing homes.

Employment of trauma informed principles in the Palabras Fuertes project: Implications for narrative research with older Latinx communities

In the US, there is a growing number of older Latinx communities. Qualitative approaches such as narrative inquiry may be fruitful endeavors to elucidate their lived experiences. However, older Latinx communities, including sexual minorities, are disproportionately exposed to social, health, and historical challenges that may result in exposure to potentially traumatic events (e.g. discrimination, illness, grief, etc.). The recognition of high rates of exposure to potentially traumatic events among participants has led to the recommended adoption of Trauma Informed (TI) principles for use in non-trauma specific research. At present, there are limited examples and discussions about the implementation of TI principles in qualitative research and our literature review yielded no discussion of the use of TI principles in narrative inquiry or with older Latinx communities. In this manuscript, we advocate for the adoption of TI principles when engaging in narrative inquiry with older Latinx adults. Second, we discuss examples of TI guided practices we employed while conducting the Palabras Fuertes study of life history narratives with older Latino immigrant gay men living in New York City. Finally, based on these experiences, we provide recommendations for incorporating TI into future narrative research with older Latinx communities.

Positive Aging and Death or Dying: A Scoping Review

BACKGROUND AND OBJECTIVES

This scoping review aims to examine the extent and the manner in which research that utilizes successful, active, productive, and healthy aging framework(s) includes death or dying.

RESEARCH DESIGN AND METHODS

An examination of peer-reviewed academic journal articles was conducted following Joanna Briggs Institute's methodological standards for scoping reviews and conforming to Arskey and O'Malley's 5-stage framework. The initial search resulted in 1,759 articles for review, and following the rigorous screening, 35 studies were included for the final review. A qualitative thematic analysis was used to identify how research utilizes the concepts of death and dying in the context of 4 positive aging models.

RESULTS

The core themes identified include (a) the absence of death and dying dimensions in positive aging models; (b) older adults' outlooks on death and dying while aging well; (c) religious and spiritual dimensions of aging well; (d) negative consequences of positive aging models without death and dying dimensions; and (e) the future of death and dying in positive aging models.

DISCUSSION AND IMPLICATIONS

The review delivers a critique by researchers on the noticeable absence of death and dying processes within the framework of successful, active, productive, and healthy aging models. These findings represent a rich opportunity for future research on these concepts.

Good death for people living with dementia: a qualitative study

BACKGROUND

Ensuring a good death is one of the primary objectives of palliative care and end-of-life care. There is insufficient evidence regarding what defines a good death for people living with dementia. Obtaining an understanding of what constitutes a good death could help improve dementia care. This study aimed to explore how multiple stakeholders perceive a good death for people living with dementia.

METHODS

This qualitative study was carried out across six prefectures in Japan. Enrollment of participants took place within dementia outpatient clinics, hospitals, daycare centers, and community centers. A total of thirty-three in-depth interviews with people living with dementia, physicians, and nurses were conducted. Six focus group discussions were performed with family caregivers and care workers. Verbatim transcripts of the interviews were prepared, and inductive content analysis was used to examine the data.

FINDINGS

Regarding the perception of a good death, the following themes were derived: (1) painless death; (2) dying in a preferred environment; (3) family's coping with loss; (4) maintaining regular life; (5) living with respect; and (6) preparation for death. All these themes are interrelated. Participants viewed a good death as a process rather than a single event.

CONCLUSION

This study identifies crucial components of a good death for people living with dementia. The findings could be used to improve dementia care.

The perception of life and death in patients with end-of-life stage cancer: A systematic review of qualitative research

PURPOSE

This study aims to clarify the perceptions on life and death among patients with the end-of-life stage cancer through a systematic review.

METHODS

The search strategy combined MeSH terminology with free text searches, and was applied to the PubMed, CINAHL, Embase, and ICHUSHI (Japan Medical Abstracts Society) databases covering from 2010 to 5/2022. To ensure the quality of the research included, the Critical Appraisal Skills Program Qualitative Studies Checklist was used. Data relating to the perceptions of life and death of patients with the end-of-life stage cancer was extracted and analyzed with reference to qualitative meta-synthesis methods.

RESULTS

Ultimately, 50 studies were included. Five themes were derived based on the perceptions of life and death of patients with the end-of-life stage cancer: despair, making sense of death, how to live the rest of life, special feelings for loved ones, and fluctuation. By making sense of death in their own way, and reconciling it with their current situation, patients with the end-of-life stage cancer, even in despair over their impending death, look ahead into the future and their surroundings and consider how they would live the remaining time they have. During this time, the special feelings they have for their loved ones make an impact.

CONCLUSIONS

An important new finding from this study lies in the fact that the patients' desire to live as ordinary people who were not patients were expressed as a face that they hid from their families. Further research is needed in low-income countries/regions.

Attitudes toward End-of-Life Resuscitation: A Psychometric Evaluation of a Novel Attitude Scale

AIM

With the advent of an aging society and the development of end-of-life care, there is an increasing need to understand the older generation's attitude toward end-of-life resuscitation. The study aimed to develop and validate a novel attitude scale toward end-of-life resuscitation in older inpatients.

METHOD

Instrumental development and a psychometric evaluation were used. First, a new attitude scale toward end-of-life resuscitation was formulated from literature views, expert content validity, and face validity. Next, the new scale was evaluated using a principal component analysis and internal consistency reliability in a sample from 106 medical-surgical inpatients in a southern Taiwan hospital 1 enrolled through convenience sampling. Serving as an indicator of concurrent validity, a logistic regression analysis was performed to analyze the association between scores on the scale and intention to discuss end-of-life CPR issues.

RESULTS

After being validated by the expert content validity and face validity, a draft of a 20-item scale was created. Throughout the exploratory factor analysis, two items with low factor loadings were removed from the draft scale and an 18-item scale of attitude was generated. This 18-item scale had a three-factor structure that accounted for 64.1% of the total variance; the three components were named 'stress, avoidance, and ignorance', 'a peaceful death', and 'self-determination and ambivalence'. The Cronbach's alpha of the total scale and three components were 0.845, 0.885, 0.879, and 0.857, respectively, which indicated a favorable reliability. Scores on the scale were significantly associated with the intention to discuss end-of-life CPR issues, which also indicated a favorable concurrent validity.

CONCLUSIONS

A 18-item attitude scale with three factors is a valid scale to measure the attitude toward end-of-life resuscitation. The result provides preliminary evidence of the psychometric properties of the scale. Further research with larger samples or other populations is required.

Characterizing end-of-life communication in families

Background

The chronic disease course can be uncertain, contributing to delayed end-of-life discussion within families resulting in missed opportunity to articulate wishes, increased decisional uncertainty, and delayed hospice care. Consistent with the Family Communication Patterns Theory (FCPT), family communication patterns may affect the quality and timing of end-of-life discussion, hospice utilization, and the experience of 'a good death.'

Objective

To assess how families' conversation and conformity orientation (spontaneity of conversation and hierarchical rigidity) form four family communication patterns (consensual, pluralistic, protective, and laissez-faire) and may be associated with the number and timing of end-of-life discussions.

Design

A cross-sectional study.

Methods

Family members of loved ones who died from chronic illnesses while in hospice (n = 56) completed online surveys including a modified Revised Family Communication Pattern instrument (RFCP) and the Chronic Illness Rating Scale (CIRS). Additional survey questions assessed the number and timing of end-of-life discussions and timing of hospice enrollment. IBM SPSS version 26 was used for descriptive analysis.

Results

Most families (42.9%) were pluralistic, reporting communication styles with high conversation and low conformity orientation; (39.29%) were protective, reporting low conversation and high conformity orientation. Pluralistic families had more end-of-life conversations than did protective families.

Conclusion

Study findings suggest that there may be a relationship between family communication pattern type and inclination toward end-of-life discussion. This first step supports future research regarding whether the FCPT can be used to predict which families may be at increased risk for ineffective or delayed end-of-life discussion. Additional variables to consider include the timing of hospice enrollment and the quality of the dying experience. Clinicians may ultimately use findings to facilitate earlier identification of and intervention for families who are at risk for poor end-of-life communication and outcomes.

Good death disrupted: Nurses' moral emotions navigating clinical and public health ethics during the first wave of COVID-19 pandemic

AIM

To explore the moral emotions that frontline nurses navigated in endeavouring to ensure a 'good death' for hospital patients and care home residents during the first wave of the COVID-19 pandemic.

BACKGROUND

Under normal circumstances, frontline staff are focused on clinical ethics, which foreground what is best for individuals and families. Public health crises such as a pandemic require staff to adapt rapidly to focus on what benefits communities, at times compromising individual well-being and autonomy. Visitor restrictions when people were dying provided vivid exemplars of this ethical shift and the moral emotions nurses encountered with the requirement to implement this change.

METHODS

Twenty-nine interviews were conducted with nurses in direct clinical care roles. Data were analysed thematically informed by the theoretical concepts of a good death and moral emotions.

RESULTS

The data set highlighted that moral emotions such as sympathy, empathy, distress and guilt were integral to the decisions participants described in striving for a good palliative experience. Four themes were identified in the data analysis: nurses as gatekeepers; ethical tensions and rule bending; nurses as proxy family members; separation and sacrifice.

CONCLUSIONS

Participants reflected on morally compromising situations and highlighted agency through emotionally satisfying workarounds and collegial deliberations that enabled them to believe that they were party to painful but morally justifiable decisions.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Nurses are required to implement national policy changes that may disrupt notions of best practice and therefore be experienced as a moral wrong. In navigating the moral emotions accompanying this shift, nurses benefit from compassionate leadership and ethics education to support team cohesion enabling nurses to prevail.

PUBLIC CONTRIBUTION

Twenty-nine frontline registered nurses participated in the qualitative interviews that inform this study.

REPORTING METHOD

The study adhered to the Consolidated Criteria for Reporting Qualitative Research checklist.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Trends and Meta-Analysis of Research on the Operation of Programs for Bereaved Families in South Korea

Purpose

This study aimed to analyze interventions for bereaved families and evaluate their effectiveness, with the ultimate goal of supporting evidence-based nursing for bereaved families.

Methods

Research trends were identified based on a search of domestic databases from January 2000 to December 2022, and a meta-analysis was conducted on interventions for bereaved families. Forty-five papers were selected, and information was extracted on participants, research design, and interventions. A meta-analysis of seven papers was performed, and the effect size was calculated.

Results

Fourteen papers dealt with interventions for middle-aged women who had lost their spouses, 20 used qualitative research methods, and 20 were on art therapy programs. Thirty studies had fewer than 10 participants, and most interventions had 60~120 minutes per session and 9~16 sessions in total. There were seven randomized controlled trials, and all studies included in the quality evaluation showed a low risk of bias. Four papers measured grief as an outcome, and the effect size was -1.9577 (95% CI -2.9206 to -0.9947), indicating that the treatment significantly decreased grief (P<0.001). Six papers measured depression as an outcome, and the effect size was -1.6775 (95% CI -2.1835 to -1.1716), showing that the treatment significantly decreased depression (P<0.001).

Conclusion

Intervention programs for bereaved families were shown to be effective in relieving grief and depression. However, programs should be developed that target middle-aged men who have lost their spouses and children who have lost their parents. Randomized controlled trials should also be conducted on interventions to reduce grief and depression.

The Emmaus Project: Aging, Illness, and Dying Among Older Christians-A Qualitative Study

Older patients have an increased risk of depression, neglect, and abuse. Studies demonstrate that spiritual and religious coping is important at times of personal crisis, but few studies explore the impact of religion on older persons' experiences of aging, illness, and impending death. This study set out to identify recurring spiritual and clinical themes shared by retirement home residents in the context of a Christian faith-based processing group. A qualitative cohort study of residents over the age of 65 was conducted at a retirement home in Chicago, Illinois. The study consisted of 8 hour-long Scripture-based processing group sessions co-led by a study researcher and the onsite chaplain. Questionnaires were administered to each group and handwritten responses were collected and analyzed to identify recurring clinical and spiritual themes. Ten participants enrolled in the group study. The questionnaire completion rate was 35% (49/140). The most recurring clinical themes included 1) events of death or terminal illness and 2) physical limitations. The most recurring spiritual themes included 1) God's presence and 2) prayer and worship. The most recurring coded theme overall was family. This study provided insight into the spiritual experiences of older Christians in one retirement home community. Increased awareness of the spiritual perspectives of the geriatric population may strengthen the doctor-patient relationship and lead to improvements in clinical care.