Concepts and definitions for "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care": a systematic review

Occupations of Terminally Ill Chinese Older Adults and Their Caregivers in Singapore: A Qualitative Exploratory Study

Occupations are everyday activities people do that bring meaning and purpose to life and is culturally shaped. This research aimed to explore the occupations of Chinese older adults living with a terminal illness and their caregivers in Singapore. Using a qualitative exploratory approach, 16 care recipient-family caregiver dyads were recruited from a local hospice provider. Semi-structured interviews were carried out and reflexive thematic analysis was employed. Three themes and seven subthemes described the challenges and changes to daily life faced by care recipients and caregivers as they adjusted to living with the terminal condition. Findings suggest that in a family-centric society, the occupations of care recipients are greatly impacted by their families. It is imperative to engage with family members in goal setting and intervention plans to facilitate therapy gains and carry-over into real life. These results may be applicable to other family-centric societies, but further research is required.

"Terminal Anorexia", Treatment Refusal and Decision-Making Capacity

Whether anorexic patients should be able to refuse treatment when this refusal potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of "terminal anorexia" suggests criteria when a move to palliative care or even physician-assisted suicide might be justified. The author argues that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision-making capacity. It should therefore be rejected.

The effect of end-of-life care awareness education on the knowledge, attitudes and behaviours of intensive care nurses: A randomized controlled trial

BACKGROUND

Education in end-of-life care (EoLC) is essential for improving the knowledge, attitudes and behaviours of intensive care nurses.

AIM

This study aimed to evaluate the effect of online awareness education, based on the End-of-Life Nursing Education Consortium, on the knowledge levels, attitudes and behaviours of intensive care nurses.

STUDY DESIGN

This single-centre randomized controlled study. This study was performed in a tertiary intensive care unit in a university-affiliated hospital. Seventy-six intensive care nurses were selected and equally randomized. In the education, the group was given an EoLC awareness education programme on an online platform as 40-60-min sessions once a week for 4 weeks. The descriptive Information Form, EoLC Knowledge Test and the Nurses' Attitudes and Behaviours towards the EoLC Scale were used. In the study, intensive care nurses' knowledge, attitude and behaviour levels towards EoLC were evaluated before and after 4 weeks (±3 days) following the education.

RESULTS

When the mean post-education scores of the nurses in the education group were compared with the control group, it was found that their mean scores on the EoLC Knowledge Test (p = .001, Cohen's d = 1.354, 95% CI = 3.240-6.549), the attitude sub-dimension (p = .001, Cohen's d = 1.520, 95% CI = 4.510-7.858), the behaviour sub-dimension (p = .001, Cohen's d = 1.425, 95% CI = 3.206-6.214) and the total attitude and behaviour (p = .001, Cohen's d = 1.927, 95% CI = 8.408-13.643) were statistically significantly higher than those of the control group.

CONCLUSION

This study showed that EoLC awareness education positively affected nurses' knowledge, attitudes and behaviours. Accordingly, planning EoLC awareness education online at regular intervals may be recommended for intensive care nurses.

RELEVANCE TO CLINICAL PRACTICE

Intensive care nurses may be given online EoLC awareness education to positively affect their knowledge, attitudes and behaviours about EoLC. Online EoLC education can be effective in terms of reaching a large number of nurses, time and cost.

Scoping review of anticancer drug utilization in lung cancer patients at the end of life

PURPOSE

This scoping review aims to deepen the understanding of end-of-life anticancer drug use in lung cancer patients, a disease marked by high mortality and symptom burden. Insight into unique end-of-life treatment patterns is crucial for improving the appropriateness of cancer care for these patients.

METHODS

Comprehensive searches were carried out in Medline and Embase to find articles on the utilization of anticancer drugs in the end of life of lung cancer patients.

RESULTS

We identified 68 publications, highlighting the methodological characteristics of studies including the timing of the research, disease condition, treatment regimen, type of treatment, and features of the treatment. We outlined the frequency of anticancer drug use throughout different end-of-life periods.

CONCLUSION

This review provides a comprehensive overview of primary studies exploring end-of-life treatments in lung cancer patients. Methodological inconsistencies pose many challenges, revealing a notable proportion of patients experiencing potential overtreatment, warranting more standardized research methods for robust evaluations.

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence

AIM

This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations.

BACKGROUND

Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex.

DESIGN

A systematic review was conducted.

DATA SOURCES

Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis.

RESULTS

Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data.

CONCLUSION

The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Advance Directives Revisited (2002 vs 2023): Are We Closer to Uniformity?

BACKGROUND AND OBJECTIVES

Advance directives (ADs) are based on state-specific statutes that vary in structure, terminology, and options. This variability leads to inconsistent end-of-life (EOL) care for patients who have executed an AD in 1 state but fall ill in another state. This study revisits a 2002 article that identified considerable differences in ADs to determine whether ADs have become more uniform.

RESEARCH DESIGN AND METHODS

ADs from all 50 states and the District of Columbia were examined to determine the frequency of document types and seven key issues. The results were compared to the 2002 study using nonparametric approaches. Mean numbers of key issues were compared using t-tests and 1-way analysis of variance.

RESULTS

Consistent with 2002, 3 states in 2023 provide statutes for a healthcare power of attorney (HCPOA). However, states offering a combined HCPOA, and living will (LW), deemed an advance directive for healthcare (ADHC), increased from 13 to 30. Between both studies, Long-Term Care increased significantly in LW and ADHC, whereas Artificial Sustenance significantly increased in LW. Despite the rising prevalence of Alzheimer's in the United States, only 10% of states included this issue in 2023.

DISCUSSION AND IMPLICATIONS

Despite evolving healthcare trends, minimal revisions have been made to ADs since 2002. This lack of uniformity can cause confusion regarding the proper understanding of EOL wishes. The authors recommend that the Uniform Act for Advance Directives be revisited to promote greater uniformity in ADs and ensure that individuals' preferences are understood and respected across different states.

Effectiveness of Virtual Reality Technology in Symptom Management of Patients at the end of life: A Systematic Review and Meta-Analysis

OBJECTIVES

The objective of this review was to explore the effectiveness of virtual reality (VR) technology in symptom management of patients at the end of life.

DESIGN

This is a systematic review and meta-analysis, which has been registered on PROSPERO (CRD42022344679).

SETTING AND PARTICIPANTS

Patients at the end of life.

METHODS

PubMed, Embase, Web of Science, the Cochrane Library, JBI, EBSCO, CNKI, Wanfang, and SinoMed were searched from inception to July 31, 2023. Search terms included "virtual reality" and "end-of-life." Articles were screened according to the inclusion and exclusion criteria. The random effects model was used to calculate the standardized mean difference (SMD), and the fixed effects model was used to calculate the mean difference (MD). The Cochrane Risk of Bias Tool 2.0 and JBI Evaluation tool were used to assess the risk of bias. The I2 statistic was used to measure heterogeneity between studies. Forest plots were used for analysis.

RESULTS

A total of 234 patients at the end of life from 3 randomized controlled trials and 6 quasi-experimental studies were included. Compared with pre-VR intervention, the pain [standardized mean difference (SMD) -0.89, 95% CI -1.29 to -0.48, P < .05], shortness of breath [mean difference (MD) -0.98, 95% CI -0.98-0.51, P < .05], depression (MD -0.62, 95% CI -0.85 to -0.40, P < .05), and anxiety (SMD -0.93, 95% CI -1.50 to 0.36, P < .05) of patients at the end of life was significantly improved after VR intervention. However, there were no significant differences observed in tiredness, drowsiness, nausea, and lack of appetite.

CONCLUSIONS AND IMPLICATIONS

VR technology can be effective in improving pain, shortness of breath, depression, and anxiety in patients at the end of life. For tiredness, drowsiness, nausea, and lack of appetite, further research is required.

Continuous Electrocardiographic Monitoring for 24 Hours Before Death in Patients with Terminal Cancer

BACKGROUND

Purposeless physiological monitoring at the end-of-life is not recommended. However, studies on how families feel regarding the death of patients with terminal cancer without continuous electrocardiographic monitoring (CEM) are lacking.

OBJECTIVES

To explore the impact on the quality of care and the feelings and psychological distress experienced by families when CEM is not used during the 24 hours preceding a patient's death.

METHODS

In this multicenter cross-sectional, self-report questionnaires were distributed to 1087 bereaved families at Japanese specialized palliative care units in 2018.

RESULTS

Out of 671 responses, 394 valid responses were analyzed. Families of nonmonitored patients (NM-group) accounted for 79.2%, while those with bedside electrocardiogram monitoring (MB-group) and remote nurse station monitoring (MC-group) comprised 11.9% and 8.9%, respectively. In the NM-group, 85.5% expressed satisfaction without CEM, which was more than 10% lower than other groups. While 14% in the NM-group desired patient monitoring, families who received adequate explanations about CEM had lower proportions compared to the MB-group (P = .021). Univariate analyses showed no significant differences in evaluations of the quality of care and families' psychological distress (mean scores of Overall Care Satisfaction, Care Evaluation Scale, Good Death Inventory, Brief Grief Questionnaires) across all groups.

CONCLUSION

While the majority of NM-group were satisfied with their patient's care without CEM, the proportion of dissatisfied families was higher than in other groups. Although not using CEM is not a major hindrance to end-of-life care for patients with terminal cancer, providing sufficient explanations may be important for satisfactory care.

The OASIS walking study-Older adults with cognitive impairment performing sit to stands and walking in transitional care programs: Protocol for a feasibility study

Older adults with cognitive impairment often experience low mobility and functional decline in hospital, transfer to facility-based transitional care programs, and have poorer outcomes compared to those without cognitive impairment. This protocol paper describes a study which aims to determine the feasibility of, satisfaction with, and efficacy of a nurse-led mobility intervention (OASIS Walking Intervention) for older adults with cognitive impairment in facility-based transitional care programs in Ontario, Canada. A quasi-experimental one-group time series feasibility study will be conducted. A sample size of 26 participants will be recruited from two transitional care programs in Ontario, Canada. Participants will receive the OASIS Walking Intervention for up to 45 minutes per session, 5 sessions per week, for 6 weeks. The intervention consists of: 1) a patient-centered communication care plan; 2) sit to stand activity; and 3) a walking program. Feasibility will be determined by: a) recruitment rate; b) retention rate; and c) adherence. Efficacy of the intervention will be determined by the change over time in older adults' lower extremity muscle strength, mobility, and functional status and by their discharge destination (home vs. nursing home). Satisfaction will be measured using the Client Satisfaction Questionnaire. Efficacy outcomes will be measured before the start of the intervention, after 3 weeks of the intervention, and immediately after 6-week intervention. Descriptive statistics will be used for measures of feasibility, satisfaction, and discharge destination. Repeated measures analysis of variance (RM-ANOVA) will be used to analyze efficacy. Ethics approval has been received for this study. Findings from the study will be used to refine the intervention for use in a definitive pilot trial. Results will be disseminated via peer-reviewed publications, international conferences, through group presentations at the study sites, and through the study site networks. Trial registration: The trial has been registered on Clinicaltrials.gov (NCT06150339).

Cardiologists' perspective on termination of pacemaker therapy-an anonymous survey among cardiologists in Germany

BACKGROUND

The patient's right to refuse pacemaker therapy is mentioned in the relevant European consensus statement but additional information is only available on deactivation of implantable cardioverter deactivator and not on other cardiac implantable electronic devices such as pacemakers. Therefore, we were interested in opinions, concerns and attitudes of cardiologists, who are the primary contact persons for such requests, since the number of patients asking for withdrawal of pacemaker therapy is likely to increase leaving cardiologists and healthcare professionals with a difficult medical but also ethical problem.

METHODS

An anonymous questionnaire was sent to all German cardiology departments (N = 288).

RESULTS

48% of cardiology departments responded by sending back 247 completed questionnaires. Most participating cardiologists were experienced when considering the duration of their professional activity. Almost all of the respondents regularly perform check-ups of pacemakers. The majority of cardiologists answering our questionnaire were prepared to deactivate a pacemaker upon patients' request, and have done so. In pacemaker dependency, however, the willingness to withdraw decreases, even if death is imminent, for fear of causing distressing symptoms, sense of being responsible for patients possible immediate death, or fear of legal consequences.

CONCLUSIONS

The survey could clearly show that uncertainties remain among cardiologists dealing with a patient's wish for withdrawal, especially in cases of pacemaker dependency. We suggest that official statements of cardiologic societies in Europe are issued to clarify ethical, legal and practical aspects of pacemaker withdrawal.

TRIAL REGISTRATION

Registered in the German Clinical Trials Register (DRKS00026168) on 30.08.2021.

End of life care for people with dementia and comorbid cancer: recent studies and research gaps

PURPOSE OF REVIEW

This narrative review examines recent research on end of life (EOL) care for people with dementia and comorbid cancer, highlighting the complexity and challenge of providing effective EOL care for this group and areas of interest for future research.

RECENT FINDINGS

People with cancer and dementia and their family/supporters have more complex care and support needs at EOL that are less well met than those of older adults with cancer alone, including questionable use of aggressive EOL care interventions, poorer access to specialist palliative care teams and poor pain management. Those diagnosed with dementia at the same time as, or after their cancer diagnosis, are at greater risk of aggressive EOL care and EOL cancer treatment and care plans that are not able to meet their care needs as dementia progresses.

SUMMARY

There is a lack of research on EOL care for people with cancer and dementia. There is little understanding of what good care for this population looks like and if and how EOL care can best meet the needs of people with cancer and dementia or their carers/supporters. More research is needed to inform improved care for this population.

Ethical and Practical Issues with the Use of Antimicrobial Agents during the End of Life

The use of antimicrobials in patients receiving end-of-life (EOL) care, which is generally defined as supportive care provided to patients anticipated to live less than 1 year, has been actively debated in the realm of palliative care medicine due to the nebulous nature of the topic. In this article, we explore the use of antimicrobial use near EOL as it relates to both the ethical and practical issues that face physicians. We also discuss the reasons underlying the scarcity of prospective studies on this topic.

Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life

BACKGROUND

Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context.

METHODS

Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order.

RESULTS

Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint.

CONCLUSIONS

Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options.

IMPLICATIONS FOR PRACTICE

Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.

Impact of Delirium Onset and Duration on Mortality in Patients With Cancer Admitted to the ICU

BACKGROUND

Little is known on the effects of delirium onset and duration on outcome in critically ill patients with cancer.

OBJECTIVES

To determine the impact of delirium onset and duration on intensive care unit (ICU) and hospital mortality and length of stay (LOS) in patients with cancer.

METHODS

Of the 915 ICU patients admitted in 2018, 371 were included for analysis after excluding for terminal disease, <24-h ICU stay, lack of active cancer and delirium. Delirium was defined as early if onset was within 2 days of ICU admission, late if onset was on day 3 or later, short if duration was 2 days or less, and long if duration was 3 days or longer. Patients were placed into 4 combination groups: early-short, early-long, late-short, and late-long delirium. Multivariate analysis controlling for sex, age, metastatic disease, and predelirium hospital LOS was performed to determine ICU and hospital mortality and LOS. Exploratory analysis of long-term survival was also performed. Restricted cubic splines were performed to confirm the use of 2 days to distinguish between early versus late onset and short versus long duration.

RESULTS

A total of 32.9% (n = 122) patients had early-short, 39.1% (n = 145) early-long, 16.2% (n = 60) late-short, and 11.9% (n = 44) late-long delirium. Late-long delirium was independently associated with increased ICU (OR 4.45, CI 1.92-10.30; P < .001) and hospital (OR 2.91, CI 1.37-6.19; P = .005) mortality and longer ICU (OR 1.97, CI 1.58-2.47; P < .001) LOS compared to early-short delirium. Early delirium had better overall survival at 18 months than late delirium. Long-term survival further improved when delirium duration was 2 days or less. Prediction heatmaps confirm the use of a 2-day cutoff.

CONCLUSION

Late delirium, especially with long duration, significantly worsens outcome in ICU patients with cancer and should be considered a harbinger of poor overall condition.

Providing end of life care in the emergency department: A hermeneutic phenomenological study

BACKGROUND

Registered nurses report the experience of delivering end of life care in emergency departments as challenging. The study aim was to understand what it is like to be a registered nurse providing end of life care to an older person in the emergency department.

METHODS

A hermeneutic phenomenological study was conducted in 2021, using semi-structured interviews with seven registered nurses across two hospital emergency departments in Queensland, Australia. Thematic analysis of participants' narratives was undertaken.

FINDINGS

Seven registered nurses were interviewed; six of whom were women. Participant's experience working in the emergency department setting ranged from 2.5-20 years. Two themes were developed through analysis: (i) Presenting the patient as a dying person; and (ii) Mentalising death in the context of the emergency department.

CONCLUSIONS

Nurses providing end of life care in the emergency department draw upon their personal and aesthetic knowing to present the dying patient as a person. The way death is mentalised suggests the need to develop empirical knowing about ageing and supportive medical care and ethical knowing to assist with the transition from resuscitation to end of life care. Shared clinical reflection on death in the emergency department, facilitated by experts in ageing and end of life care is recommended.

Expectation, emotion and the built environment: experiences of occupying hospital spaces as a loved one nears the end of life

Following a 3-year long research project that gathered 146 views, including those of palliative care patients, family members, medical staff, administrators, architects and government representatives, this paper explores the hypothesis that motivated this work; a hunch that the built environment affects us most during times of intense vulnerability. Of these 146 people, only a small handful could provide insight relative to the experience of occupying hospital spaces as a loved one nears the end of life. This article honours these stories and discusses them in relation to my own observations and experiences. The article is thus part observation, part participant interview, part autoethnography. Findings already published from the broader study have spoken to the importance of fresh air, access to nature, spaces for spending time with family, as well as alone, and ensuring people feel comfortable to enact rituals of home within the hospital. Yet the accounts discussed here are different. They speak to the subtle ways that hospital environments communicate when emotions are raw, and people are at their most exhausted. They speak to the ways that aesthetics are felt; and make evident that notions of homeliness must encompass far more at the end of life. A sense of welcome is not a nicety but a need, as is comfort, and what might be termed 'imaginative respite'-the idea that the built environment might somehow alleviate the focus on an unbearable reality. These accounts speak to the difficulty of navigating grief, and a hopeful expectation that the built environment might somehow soften the edges of this experience. In focusing on these stories, this article contributes a deeper understanding of what is really at stake when we design for palliative care.

Collaboration, coordination and communication as facilitators of transitions for patients with advanced cancer: a scoping review linked to the Pal-Cycles project

BACKGROUND

Person-centred care is becoming increasingly recognised as an important element of palliative care. The current review syntheses evidence in relation to transitions in advanced cancer patients with palliative care needs. The review focuses on specific elements which will inform the Pal-Cycles programme, for patients with advanced cancer transitioning from hospital care to community care. Elements of transitional models for cancer patients may include, identification of palliative care needs, compassionate communication with the patient and family members, collaborative effort to establish a multi-dimensional treatment plan, review and evaluation of the treatment plan and identification of the end of life phase.

METHODS

A scoping review of four databases (MEDLINE, EMBASE, CINAHL, PsycINFO) was conducted to identify peer-reviewed studies published from January 2013 to October, 2022. A further hand-search of references to locate additional relevant studies was also undertaken. Inclusion criteria involved cancer patients transitions of care with a minimum of two of components from those listed above. Studies were excluded if they were literature reviews, if transition of care was related to cancer survivors, involved non-cancer patients, had paediatric population, if the transition implied a change of therapy and or a lack of physical transit to a non-hospital place of care. This review was guided by Arksey and O'Malley's framework and narrative synthesis was used.

RESULTS

Out of 5695 records found, 14 records were selected. Transition models identified: increases in palliative care consultations, hospice referrals, reduction in readmission rates and the ability to provide end of life care at home. Transition models highlight emotional and spiritual support for patients and families. No uniform model of transition was apparent, this depends on the healthcare system where it is implemented.

CONCLUSIONS

The findings highlight the importance of collaboration, coordination and communication as central mechanisms for transitional model for patients with advanced cancer. This may require careful planning and will need to be tailored to the contexts of each healthcare system.

An Operational Definition of End-of-Life Healthcare: A Complex and Subjective Construct

Comprehensively defining end-of-life healthcare is a challenge due to the diverse areas of healthcare involved, the various stakeholders, and the range of patient options. This qualitative study examined many areas of end-of-life healthcare including quality, areas for improvement, and healthcare policy in Tennessee, in which the definition of end-of-life healthcare was a focus. Data were collected using semi-structured interviews with 19 participants who included end-of-life healthcare experts and Tennessee legislators. Through this research an operational definition of end-of-life healthcare, encompassing five concepts, was developed. Concepts include: a diagnosis, a timeframe, type of care, location of care, and planning for the future. When considered together, they are the embodiment of what end-of-life healthcare encompasses. Not in a one-fits-all definition, but individually tailored. An understanding of what end-of-life healthcare denotes is essential to maintaining open communication, high quality standards of care, and the protection of patient autonomy.

Assisted death in eating disorders: a systematic review of cases and clinical rationales

Background

Assisted dying for reasons solely related to an eating disorder (ED) has occurred in multiple countries, including those which restrict the practice to individuals with a terminal condition. The aims of this systematic review were to (1) identify all known cases of assisted deaths among patients with EDs and (2) describe the clinical rationales used to grant patients' requests for assisted death.

Methods

We conducted a systematic search of peer-reviewed studies and publicly available government reports to identify cases of assisted death in patients with EDs. In reports that included qualitative data about the case, clinical rationales were extracted and grouped into domains by qualitative content analysis.

Results

We identified 10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024. Clinical rationales were categorized into three domains: irremediability, terminality, and voluntary request. Reports emphasized that patients with EDs who underwent assisted death had terminal, incurable, and/or untreatable conditions and had adequate decision-making capacity to make a life-ending decision. Most government reports did not include descriptive-enough data to verify psychiatric conditions.

Conclusion

The results of our systematic review underscore considerable gaps in the reporting of assisted death in patients with psychiatric conditions, posing substantial concerns about oversight and public safety. In many cases, the clinical rationales that were used to affirm patients with EDs were eligible for assisted death lack validity and do not cohere with empirical understanding.

Nomenclature in Palliative and Kidney Supportive Care: Not Just at the End-of-Life

The multidimensional view of disease is fundamental in the care of complex diseases such as chronic kidney disease (CKD). It is appropriate to define and unify concepts that allow the different professionals involved in care to provide a multidisciplinary approach tailored to the needs of each individual. Given the increasing incidence of CKD worldwide and the fact that the disease may progress at different rates, there is a need to establish personalized, comprehensive approaches for each patient and their families at an earlier stage. This approach goes beyond the simple control of uremic symptoms or congestion and consists of addressing not only symptomatic but also functional, social and coping problems at an early stage, facilitating decision making both in the CKD and in acute situations, potentially irreversible or interventions that do not improve life expectancy. To ensure excellence in care, it is important to assess indicators of palliative care and kidney support, such as the presence of advance and shared care planning, the inclusion of psychosocial, ethical, spiritual and bereavement care. This enables the provision of comprehensive, humanized, and high-quality care for patients and their families. Palliative and kidney care is not just about patients in the last days of life. Defining, unifying, and evaluating the concepts will allow them to be applied in a timely manner at each specific moment of the CKD trajectory.

The Cost of Dying Exhibition: public, professional and political reactions to a visual exhibition depicting experiences of poverty at the end of life

Public health approaches to palliative care are internationally endorsed for their potential to improve the social determinants of dying such as energy costs, transport and housing. Enhancing public understanding of inequities in end of life experiences, which exist even in economically advanced countries, is vital if the value of public health approaches are to be endorsed and invested in. Visual exhibitions have a strong tradition of raising awareness and influencing public health discourse. The UK-based Cost of Dying exhibition (April-August 2023) presented real examples of how financial hardship and deprivation intersect with end of life experience through professional portraits, photovoice imagery taken by individuals at the end of their lives, and digital stories co-produced with bereaved relatives. Three iterations of the exhibition were displayed at public venues and a health conference. Evaluation methods comprised anonymous feedback cards (n=208), panel discussions and social media reactions. Thematic analysis was used to identify themes within the feedback. The emotional resonance of the exhibition was a key theme, with attendees expressing sadness, anger, empathy and hope. Visitors found the exhibition thought-provoking and expressed that it countered existing stereotypes about what it means to experience financial hardship at the end of life. The exhibition spurred calls for change, with some attendees questioning in what capacity they could help. Individuals with expertise in end of life care reported that the imagery validated their professional experiences. In conclusion, the Cost of Dying exhibition made visible the struggles endured by individuals confronting financial hardship and material deprivation at the end of life. Such exhibitions can challenge the traditional view of dying as a swift process taking place sequestered in institutions, revealing that it often unfolds over time and individuals may continue to live at home in the community, struggling with unmet needs and unresponsive state services.

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

The Extent to Which the Wish to Donate One's Organs After Death Contributes to Life-Extension Arguments in Favour of Voluntary Active Euthanasia in the Terminally Ill: An Ethical Analysis

In terminally ill individuals who would otherwise end their own lives, active voluntary euthanasia (AVE) can be seen as life-extending rather than life-shortening. Accordingly, AVE supports key pro-euthanasia arguments (appeals to autonomy and beneficence) and meets certain sanctity of life objections. This paper examines the extent to which a terminally ill individual's wish to donate organs after death contributes to those life-extension arguments. It finds that, in a terminally ill individual who wishes to avoid experiencing life he considers to be not worth living, and who also wishes to donate organs after death, AVE maximizes the likelihood that such donations will occur. The paper finds that the wish to donate organs strengthens the appeals to autonomy and beneficence, and fortifies the meeting of certain sanctity of life objections, achieved by life-extension arguments, and also generates appeals to justice that form novel life-extension arguments in favour of AVE in this context.

End-of-Life Symptoms in Adult Patients With Stroke in the Last Two Years of Life: An Integrative Review

BACKGROUND

Stroke is a leading cause of death globally, yet End-of-Life (EOL) symptoms and their management in these patients are not well understood.

PURPOSE

This integrative review aims to critique and synthesize research on EOL symptoms and symptom management in adult patients with stroke in the last 2 years of life in all settings.

METHODS

The Whittemore and Knafl integrative review methodology guided this review. PubMed, CINAHL, Scopus, Web of Science, and Google Scholar were used for the literature search. Included studies were published in English and quantitatively examined symptoms and symptom management. Quality appraisal was guided by the Effective Public Health Practice Project (EPHPP) assessment tool.

RESULTS

Seven studies, all rated weak, were included in this review. A total of 2175 adult patients from six countries were represented. Results are classified into three main themes: EOL symptom experience, symptom assessment, and symptom management. Commonly reported EOL symptoms among adults with stroke include both stroke-specific (dysphagia, dysarthria) and non-specific symptoms (pain, dyspnea, constipation, and psychological distress). However, communication difficulties and the infrequent use of standardized tools for symptom assessment limit what is known about the EOL symptom experience. Although the relief of pain is generally well-documented, dyspnea and anxiety are much more poorly controlled.

CONCLUSIONS

There is a need for better assessment and management of EOL symptoms in patients with stroke. Established palliative and EOL care guidelines need to be incorporated into clinical practice to ensure access to high-quality care.

Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice

End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.

Influencing factors of home hospice care needs of the older adults with chronic diseases at the end of life in China: a cross-sectional study

Introduction

Chronic diseases are becoming a serious threat to the physical and mental health of older people in China as their aging process picks up speed. Home hospice care addresses diverse needs and enhances the quality of life for older adult individuals nearing the end of life. To ensure the well-being of chronically ill older adults at the end of life, it is vital to explore and assess the multidimensional hospice needs of terminally ill older individuals in their homes. The aim of this study was to investigate the current situation of home hospice care needs of Chinese older adults with chronic diseases at the end of life, and to analyze the influencing factors (sociodemographic and disease-related factors).

Methods

In this cross-sectional study, 247 older adult people with chronic diseases at the end of life were selected from the communities of 4 community health service centers in Jinzhou City, Liaoning Province from June to October 2023 by random sampling method. A general information questionnaire and the home hospice care needs questionnaire developed by our research group were used to investigate. Independent samples t-test or one-way ANOVA was used to compare the differences in the scores of different characteristics, and the factors with significant differences were selected for multivariate linear regression analysis to determine the final influencing factors.

Results

The total score of home hospice needs of the dying older adult was 115.70 ± 12, with the mean scores for each dimension in descending order being Information Needs (3.96 ± 0.61), Social Support Needs (3.96 ± 0.44), Spiritual Needs (3.92 ± 0.43), Physical Needs (3.60 ± 0.59), Psychological Needs (3.37 ± 0.65). Status of residence, duration of illness (year), the type of disease, and self-care ability were influential factors in the total score of home hospice needs.

Discussion

The need for hospice care for the terminally ill older adult is high, and healthcare professionals should implement services according to the influencing factors of need to meet their multidimensional needs and improve their quality of life.

Use of the supportive and palliative care indicators tool (SPICT™) for end-of-life discussions: a scoping review

BACKGROUND

In order to mitigate the distress associated with life limiting conditions it is essential for all health professionals not just palliative care specialists to identify people with deteriorating health and unmet palliative care needs and to plan care. The SPICT™ tool was designed to assist with this.

AIM

The aim was to examine the impact of the SPICT™ on advance care planning conversations and the extent of its use in advance care planning for adults with chronic life-limiting illness.

METHODS

In this scoping review records published between 2010 and 2024 reporting the use of the SPICT™, were included unless the study aim was to evaluate the tool for prognostication purposes. Databases searched were EBSCO Medline, PubMed, EBSCO CINAHL, APA Psych Info, ProQuest One Theses and Dissertations Global.

RESULTS

From the search results 26 records were reviewed, including two systematic review, two theses and 22 primary research studies. Much of the research was derived from primary care settings. There was evidence that the SPICT™ assists conversations about advance care planning specifically discussion and documentation of advance care directives, resuscitation plans and preferred place of death. The SPICT™ is available in at least eight languages (many versions have been validated) and used in many countries.

CONCLUSIONS

Use of the SPICT™ appears to assist advance care planning. It has yet to be widely used in acute care settings and has had limited use in countries beyond Europe. There is a need for further research to validate the tool in different languages.

A retrospective descriptive study of medical record documentation of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds

INTRODUCTION

Communication between clinicians and family members of patients about treatment limitation practices is essential to care-planning and decision-making. For patients and family members from culturally diverse backgrounds, there are additional considerations when communicating about treatment limitations.

OBJECTIVE

The objective of this study was to explore how treatment limitations are communicated with family members of patients from culturally diverse backgrounds in intensive care.

METHODS

A descriptive study using a retrospective medical record audit was undertaken. Medical record data were collected from patients who died in 2018 in four intensive care units in Melbourne, Australia. Data are presented using descriptive and inferential statistics and progress note entries.

RESULTS

From 430 adult deceased patients, 49.3% (n = 212) of patients were born overseas, 56.9% (n = 245) identified with a religion, and 14.9% (n = 64) spoke a language other than English as their preferred language. Professional interpreters were used in 4.9% (n = 21) of family meetings. Documentation about the level of treatment limitation decisions were present in 82.1% (n = 353) of patient records. Nurses were documented as present for treatment limitation discussions for 49.3% (n = 174) of patients. Where nurses were present, nurses supported family members, including reassurance that end-of-life wishes would be respected. There was evidence of nurses coordinating healthcare activities and attempting to address and resolve difficulties experienced by family members.

CONCLUSIONS

This is the first known Australian study to explore documented evidence of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds. Many patients have documented treatment limitations, yet there are a proportion of patients who die before treatment limitations can be discussed with family, which may influence the timing and quality of end-of-life care. Where language barriers exist, interpreters should be used to better ensure effective communication between clinicians and family. Greater provision for nurses to engage in treatment limitation discussions is required.

Clinician and Family Caregiver Perspectives on Deprescribing Chronic Disease Medications in Older Nursing Home Residents Near the End of Life

INTRODUCTION

Nursing home (NH) residents with limited life expectancy (LLE) who are intensely treated for hyperlipidemia, hypertension, or diabetes may benefit from deprescribing.

OBJECTIVE

This study sought to describe NH clinician and family caregiver perspectives on key influences on deprescribing decisions for chronic disease medications in NH residents near the end of life.

METHODS

We recruited family caregivers of veterans who recently died in a Veterans Affairs (VA) NH, known as community living centers (CLCs), and CLC healthcare clinicians (physicians, nurse practitioners, physician assistants, pharmacists, registered nurses). Respondents completed semi-structured interviews about their experiences with deprescribing statin, antihypertensive, and antidiabetic medications for residents near end of life. We conducted thematic analysis of interview transcripts to identify key themes regarding influences on deprescribing decisions.

RESULTS

Thirteen family caregivers and 13 clinicians completed interviews. Key themes included (1) clinicians and caregivers both prefer to minimize drug burden; (2) clinical factors strongly influence deprescribing of chronic disease medications, with differences in how clinicians and caregivers weigh specific factors; (3) caregivers trust and rely on clinicians to make deprescribing decisions; (4) clinicians perceive caregiver involvement and buy-in as essential to deprescribing decisions, which requires time and effort to obtain; and (5) clinicians perceive conflicting care from other clinicians as a barrier to deprescribing.

CONCLUSIONS

Findings suggest a need for efforts to encourage communication with and education for family caregivers of residents with LLE about deprescribing, and to foster better collaboration among clinicians in CLC and non-CLC settings.

How clinicians recognise people who are dying: An integrative review

BACKGROUND

Timely recognition of dying is important for high quality end-of-life care however, little is known about how clinicians recognise dying. Late recognition is common and can lead to futile treatment that can prolong or increase suffering and prevent a change in the focus of care.

AIM

To explore how clinicians caring for dying people recognise that they are in the last days or hours of life, as well as the factors that influence the recognition of dying.

DESIGN

A systematically constructed integrative review of the literature.

METHODS

Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature, PsycInfo and Allied and Complementary Medicine were searched in July 2022. Papers were included if they were original research, discussed how clinicians recognise dying, available in English language and published in 2012 or later. A constant comparison approach was applied to the analysis and synthesis of the literature.

RESULTS

24 papers met the inclusion criteria. There were 3 main categories identified: 'Clues and signals' refers to prompts and signs that lead a clinician to believe a person is dying, incorporating the sub-categories 'knowing the patient over time', and 'intuition and experience'. 'Recognition by others' is where clinicians come to recognise someone is dying through others. This can be through a change in the context of care such as a tool or care plan or by communication with the team. 'Culture, system and practice' refers to the cultural beliefs of a setting that influences awareness of dying and denial of death as a possibility and avoidance of naming death and dying directly. System and practice of the setting also impact on recognition of dying. This involves work pace and intensity, shift systems and timing of senior reviews of patients. Uncertainty and its impact on recognition of dying are evident throughout the findings of this review. The seeking of certainty and the absence of the possibility of dying contributes to late recognition of dying.

DISCUSSION

Recognition of dying is a complex process that occurs over time, involving a combination of intuition and gathering of information, that is influenced by contextual factors. A culture where dying is not openly acknowledged or even named explicitly contributes to late recognition of dying. A shared language and consistent terminology for explicitly naming dying are needed. Uncertainty is intrinsic to the recognition of dying and therefore a shift to recognising the possibility of dying rather than seeking certainty is needed.

REGISTRATION

(PROSPERO) CRD42022360900. Registered September 2022.

Aggressive anticancer treatment in the last 2 weeks of life

BACKGROUND

There is a concern that terminally ill cancer patients may be aggressively treated due to the rapidly growing possibilities of anticancer treatment. The aim of this study was to evaluate the use of anticancer treatment at the end of life (EoL).

MATERIALS AND METHODS

This retrospective study included adult patients with advanced solid cancers who were treated at the Institute of Oncology Ljubljana and died of cancer between January 2015 and December 2019. A multiple logistic regression model was used to assess an association between the aggressiveness of anticancer treatment (i.e. systemic therapy, radiotherapy and surgery) in the last 2 weeks of life and year of death, age at death, sex, prognosis of cancer and enrolment into the specialist palliative care (SPC).

RESULTS

We included 1736 patients in our analysis. Overall, 13.7% of patients were enrolled into the SPC and 14.4% received anticancer treatment in the last 2 weeks of life. The odds of receiving anticancer treatment significantly increased over time [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.04-1.27]. There was an increased use of novel systemic therapy (e.g. small-molecule targeted therapy and immunotherapy) at the EoL. Older patients had significantly lower odds to receive anticancer treatment in the last 2 weeks of life as compared to younger patients (OR 0.96, 95% CI 0.95-0.98). As compared to patients receiving only a standard oncology care, those also enrolled into the SPC had significantly lower odds for anticancer treatment in the last 2 weeks of life (OR 0.22, 95% CI 0.12-0.43).

CONCLUSIONS

Terminally ill cancer patients have increased odds for receiving anticancer treatment, especially novel systemic therapies, in the last 2 weeks of life. Younger patients and those not enrolled into the SPC are at particular risk for anticancer treatment at the EoL.

The Effect of Death Anxiety on Work Passion: Moderating Roles of Work Centrality and Work Connection

Fear of death is an emotional manifestation of the instinct for self-preservation. Any threat to our existence induces an anxiety response. Death anxiety can trigger obsessive-compulsive behaviours, such as an obsessive passion for work. Using a sample of 314 participants (68.2% female), with a mean age of 38.97 years (SD = 10.36), this study sought to observe the predictive effect of death anxiety on work passion, as well as the moderating effect of work-family centrality and connection on the relationship between anxiety and passion. The results revealed that death anxiety negatively affects harmonious passion, and positively affects obsessive passion. Work centrality did not moderate the influence of death anxiety on harmonious and obsessive passion. Nonetheless, work connection moderated the influence of death anxiety on harmonious passion. The negative influence of death anxiety on harmonious passion was greater in a group with high work connection than a group with low connection.

Impact of palliative care at end-of-life Covid-19 patients - a small-scale pioneering experience

BACKGROUND

In March 2020, the outbreak caused by the SARS-CoV-2 virus was declared a pandemic, resulting in numerous fatalities worldwide. To effectively combat the virus, it would be beneficial to involve professionals who specialize in symptom control for advanced illnesses, working closely with other specialties throughout the illness process. This approach can help manage a range of symptoms, from mild to severe and potentially life-threatening. No studies have been conducted in Portugal to analyse the intervention of Palliative Medicine at the end of life of Covid-19 patients and how it differs from other specialties. This knowledge could help determine the importance of including it in the care of people with advanced Covid-19.

OBJECTIVES

The objective of this study is to examine potential differences in the care provided to patients with Covid-19 during their Last Hours and Days of Life (LHDOL) between those who received care from Palliative Medicine doctors and those who did not.

METHODS

This is a retrospective cohort study spanning three months (Dec 2020 to Feb 2021), the duration of the Support Unit especially created to deal with Covid-19 patients. The database included clinical files from 181 patients admitted to the Support Unit, 27 of which died from Covid-19.

RESULTS

Statistically significant differences were identified in the care provided. Specifically, fewer drugs were administered at the time of death, including drugs for dyspnoea, pain and agitation, suspension of futile devices and use of palliative sedation to control refractory symptoms.

CONCLUSIONS

End-of-life care and symptomatic control differ when there's regular follow-up by Palliative Medicine, which may translate less symptomatic suffering and promote a dignified and humane end of life.

Discrimination against the dying

The purpose of this paper is to identify a kind of discrimination that has hitherto gone unrecognised. 'Terminalism' is discrimination against the dying, or treating the terminally ill worse than they would expect to be treated if they were not dying. I provide four examples from healthcare settings of this kind of discrimination: hospice eligibility requirements, allocation protocols for scarce medical resources, right to try laws and right to die laws. I conclude by offering some reflections on why discrimination against the dying has been hard to identify, how it differs from ageism and ableism, and its significance for end-of-life care.

Frequency of anticancer drug use at the end of life: a scoping review

PURPOSE

Anticancer drug use at the end of life places potential extra burdens on patients and the healthcare system. Previous articles show variability in methods and outcomes; thus, their results are not directly comparable. This scoping review describes the methods and extent of anticancer drug use at end of life.

METHODS

Systematic searches in Medline and Embase were conducted to identify articles reporting anticancer drug use at the end of life.

RESULTS

We selected 341 eligible publications, identifying key study features including timing of research, disease status, treatment schedule, treatment type, and treatment characteristics. Among the subset of 69 articles of all cancer types published within the last 5 years, we examined the frequency of anticancer drug use across various end of life periods.

CONCLUSION

This comprehensive description of publications on anticancer drug use at end of life underscores the importance of methodological factors when designing studies and comparing outcomes.

Interventions for Family Caregivers of Patients Receiving Palliative/Hospice Care at Home: A Scoping Review

There is a need for understanding the breadth of interventions for caregivers of individuals receiving hospice care at home, given the important role caregivers play in caring and the negative outcomes (e.g., depression) associated with their caregiving. Previous reviews were limited in scope to certain types of interventions or patient populations. The objective of this scoping review was to broadly examine the interventions targeting caregivers who provide care to terminally ill patients in home, with the purpose of (1) describing the characteristics of these interventions, (2) discussing key outcomes, limitations, and knowledge gaps, (3) highlighting intervention strengths, and (4) proposing future research directions. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Intervention studies that met the inclusion criteria and that were published up until October 2022 were obtained from the following databases: Ovid MEDLINE, Ovid EMBASE, CINAHL (EBSCO), and The Cochrane Library (Wiley). We analyzed 76 studies describing 55 unique interventions that took place in 14 countries. Interventions were largely delivered by nurses (n = 18, 24%), followed by an interdisciplinary team (n = 16, 21%), a health care provider (n = 10, 13%), research staff (n = 10, 13%), social worker (n = 5, 7%), and others (n = 11, 15%). Six interventions (8%) were self-administered. The most measured outcome was caregiver quality of life (n = 20, 26%), followed by anxiety (n = 18, 24%) and burden (n = 15, 20%). Missing data on patient and caregiver characteristics (i.e., age, gender) were common, and less than half of studies (n = 32, 42%) reported race/ethnicity data. Our review highlighted the current state of interventions for caregivers of patients receiving hospice care at home. Many of the interventions were in the early phases of development, raising the need for future studies to look at efficacy, effectiveness, and the ability to implement interventions in real-world settings.

The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians

CONTEXT

The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication.

OBJECTIVES

We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice.

METHODS

We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers.

RESULTS

Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice.

CONCLUSION

Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness.

Current definitions of advanced multimorbidity: a protocol for a scoping review

INTRODUCTION

People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice.

METHODS AND ANALYSIS

Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.

Patients' Perspective on Termination of Pacemaker Therapy-A Cross-Sectional Anonymous Survey among Patients Carrying a Pacemaker in Germany

OBJECTIVE

To determine the opinions of patients regarding the withdrawal of pacemaker therapy.

PARTICIPANTS AND METHODS

A cross-sectional anonymous questionnaire was administered to patients visiting an outpatient cardiologic clinic for routine follow-up visits of pacemaker therapy or patients carrying a pacemaker admitted to a hospital between 2021 and 2022.

RESULTS

Three-hundred and forty patients answered the questionnaire. A total of 56% of the participants were male. The mean age was 81 years. The majority of respondents were very comfortable with their PM and felt well informed, with one exception: more than half of respondents were missing information on withdrawal of pacemaker therapy. Almost two-thirds wanted to decide for themselves if their pacemaker therapy was withdrawn regardless of whether they were ill or healthy. Almost 60% of patients would like the pacemaker to be turned off when dying. Women expressed this wish significantly more often than men.

CONCLUSION

Our survey shows that patients prefer to be informed on issues regarding the withdrawal of pacemakers as early as preimplantation. Also, patients would like to be involved in decisions that have to be made at the end of life, including decisions on withdrawal. Offers of conversations about this important issue should include information on special features of the patient's pacemaker, e.g., the absence or presence of pacemaker dependency. Knowledge about the pacemaker's functionality may prevent distress among individuals nearing their end of life when, for example, under the false impression that timely deactivation may allow for a more peaceful death.

Self-management of patients with tracheostomy in the home setting: a scoping review

PURPOSE

The aim of this study was to create a model of patient-centered outcomes with respect to self-management tasks and skills of patients with a tracheostomy in their home setting.

METHODS

A scoping review using four search engines was undertaken (Medline, CINAHL, PsycINFO, Cochrane Library) to identify studies relevant to this issue and published since 2000. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statements for Scoping Reviews (PRISMA-ScR), the Joanna Briggs Institute (JBI) approach of conducting and reporting a scoping review, and the Participants, Concept, Context (PCC) scheme were employed. The following elements of the framework synthesis study data were screened, and presented based on the self-management model of Lorig and Holman.

RESULTS

34 publications from 17 countries met the criteria for study inclusion: 24 quantitative, 8 qualitative and 2 mixed methods designs. Regarding the dimensions of self-management, 28 articles reported on "managing the therapeutic regimen", 27 articles discussed "managing role and behavior changes", and 16 articles explored "managing emotions". A model of self-management of patients with tracheostomy was developed, which placed the patient in the center, since it is this individual who is completing the tasks and carrying out his or her skill sets.

CONCLUSION

This scoping review represents the first comprehensive overview and modeling of the complex self-management tasks and skills required of patients with tracheostomy in their home setting. The theoretical model can serve as a cornerstone for empirical intervention studies to better support this patient-centered outcome for this population in the future.

Unique characteristics of end-of-life hospitalizations in Parkinson disease

Introduction

Persons with Parkinson disease (PD) are hospitalized at higher rates, have longer lengths of stay, and are more likely to die in the hospital than age-matched peers. Although prior studies have compared inpatient outcomes between persons with and without PD, little is known about inpatient outcomes across the PD trajectory, or whether hospitalizations occurring in the last 6 months of life differ from earlier hospitalizations.

Methods

This cross-sectional study compared Medicare Part A and B beneficiaries aged 65 and older with a qualifying PD diagnosis who were hospitalized in 2017: decedents who died between 7/1/2017 and 12/31/2017 from all causes and were hospitalized at least once in their last 6 months of life, and non-decedents who were hospitalized between 1/1/2017 and 6/30/2017 and lived 6 or more months after discharge. End-of-life (EoL) hospitalizations were defined as those occurring in the last 6 months of life. Descriptive analyses compared patient-level variables (e.g., demographics, comorbidities, treatment intensity) and encounter-level variables (e.g., length of stay, total charges) between groups. Multivariable logistic regression models also compared rates of intensive care unit (ICU) admission and 30-day readmission between hospitalized decedents and hospitalized non-decedents, adjusting for age, sex, race/ethnicity, rural residence, and Charlson Comorbidity Index Score.

Results

Of 26,492 Medicare decedents with PD, 16,187 (61.1%) were hospitalized in their last 6 months of life. Of 347,512 non-decedents with PD, 62,851 (18.1%) were hospitalized in a 6-month period. Hospitalized decedents were slightly older than hospitalized non-decedents (82.3 [SD 7.40] vs. 79.5 [SD 7.54] years) and had significantly more comorbidities. Compared to non-EoL hospitalizations, EoL hospitalizations were slightly longer (5 [IQR 3-9] vs. 4 [IQR 3-7] days) and more expensive based on total charges per admission ($36,323 [IQR 20,091-69,048] vs. $32,309 [IQR 18,789-57,756]). In covariate-adjusted regression models using hospitalized non-decedents as the reference group, hospitalized decedents were more likely to experience an ICU admission (AOR 2.36; CI 2.28-2.45) and 30-day readmission (AOR 2.43; CI 2.34-2.54).

Discussion

Hospitalizations occurring in the last 6 months of life among persons with PD in the United States are longer, more costly, and more resource intensive than earlier hospitalizations and may stem from medical comorbidities. Once hospitalized, ICU admission and 30-day readmission may aid in prognostication and serve as markers of transition to the EoL period.

Knowledge and Practice Behaviors Toward the Care of the Dying Among Chinese Oncology Nurses: A Cross-Sectional Survey

The quality of care provided to patients with cancer at the end of their lives remains unsatisfactory, especially during their last days and hours of life. This study aimed to investigate knowledge and practice behaviors of oncology nurses in relation to the care of the dying and to analyze the influencing factors. A convenience sample of 222 oncology nurses was recruited from 14 hospitals in Beijing, China, in January 2022. These nurses completed an online survey that included a demographic and work characteristics questionnaire and knowledge and practice behavior questionnaires regarding the care needs of dying cancer patients. The self-perceived knowledge and practice behavior of oncology nurses toward the care of the dying were found to be moderate. However, their understanding of airway management, restlessness, and delirium management was insufficient. In addition, their ability to effectively communicate recommendations for discontinuing unnecessary procedures, medications, treatments, and monitoring was inadequate. Nurses' previous end-of-life care education and experience of caring for dying patients influenced their knowledge. Nurses' practice settings, experience of caring for dying patients, and their knowledge were key factors in shaping their behaviors. Providing targeted continuing education for nurses in hospital settings and exploring the nursing pathway may be important ways to bridge their knowledge gap and enhance their practice behaviors toward caring for dying patients.

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.

Determinants of Attitude Toward End-of-Life Care Among Junior Physicians: Findings from a Nationwide Survey in Japan

Background

Physicians' attitudes can be critical in quality end-of-life care. However, the determinants of the attitudes and whether the attitudes can be modified remain unclear.

Objectives

To investigate factors correlated with physicians' positive attitudes toward end-of-life care and whether these attitudes are modifiable through acquired factors (e.g., education or mentorship).

Design

A nationwide survey was conducted in 300 institutions and selected randomly from 1037 clinical training hospitals in Japan.

Participants

From each selected institution, two resident physicians of postgraduate year (PGY) 1 or 2 and two clinical fellows from PGY 3-5 were requested to answer the survey.

Measurements

The primary outcome was the Frommelt Attitudes Toward the Care of the Dying (FATCOD) scale score. Factors (e.g., the respondents' age, sex, number of years of clinical experience, training environment, religion, and beliefs around death) were examined for correlation with FATCOD score.

Results

In all, 198 physicians and 134 clinical fellows responded to the survey (response rate: 33.0% and 22.3%, respectively). Factors with the strongest correlation with FATCOD scores were mostly unmodifiable factors (e.g., being female and one's beliefs around death). Modifiable factors were also identified-number of patient deaths experienced, level of interest in palliative care, availability of support from senior mentors, and frequency of consultation with nonphysician medical staff.

Conclusion

Physicians' attitudes toward end-of-life care correlate more strongly with nonmodifiable factors, but attitudes can be meaningfully improved via mentoring by senior physicians. Future studies are warranted to determine the effective interventions to foster positive attitudes among physicians involved in end-of-life care.

Treatment with anticancer drugs for advanced pancreatic cancer: a systematic review

BACKGROUND

Patients with advanced pancreatic cancer have a poor prognosis and high burden of cancer-related symptoms. It is necessary to assess the trade-off of clinical benefits and possible harms of treatments with anticancer drugs (TAD). This systematic review aims to compare the effectiveness of TAD versus supportive care or no treatment, considering all patient-important outcomes.

METHODS

We searched PubMed, Embase, Cochrane Library, and Epistemonikos. Two reviewers performed selection, data extraction and risk of bias assessment. We assessed certainty of the evidence using the GRADE approach.

RESULTS

We included 14 randomised controlled trials. Chemotherapy may result in a slight increase in overall survival (MD: 2.97 months (95%CI 1.23, 4.70)) and fewer hospital days (MD: -6.7 (-8.3, -5.1)), however, the evidence is very uncertain about its effect on symptoms, quality of life, functional status, and adverse events. Targeted/biological therapy may result in little to no difference in overall survival and a slight increment in progression-free survival (HR: 0.83 (95%CI 0.63, 1.10)), but probably results in more adverse events (RR: 5.54 (95%CI 1.24, 23.97)). The evidence is very uncertain about the effect of immunotherapy in overall survival and functional status.

CONCLUSIONS

The evidence is very uncertain about whether the benefits of using treatment with anticancer drugs outweigh their risks for patients with advanced pancreatic cancer. This uncertainty is further highlighted when considering immunotherapy or a second line of chemotherapy and thus, best supportive care would be an appropriate alternative. Future studies should assess their impact on all patient-important outcomes to inform patients in setting their goals of care.

Psychiatric Comorbidities and Outcomes in Palliative and End-of-Life Care: A Systematic Review

BACKGROUND

Although psychiatric comorbidities are common among individuals at end of life, their impact on outcomes is poorly understood.

METHODS

We conducted a systematic literature review of six databases following preferred reporting items for systematic reviews and meta-analyses guidelines and aimed at assessing the relationship between psychiatric comorbidities and outcomes in palliative and end-of-life care. Six databases were included in our search. This review is registered on PROSPERO (CRD42022335922).

RESULTS

Our search generated 7472 unique records. Eighty-eight full texts were reviewed for eligibility and 43 studies were included in the review. Clinically, psychiatric comorbidity was associated with poor quality of life, increased physical symptom burden, and low function. The impact of psychiatric comorbidity on health utilization varied, though many studies suggested that psychiatric comorbidity increased utilization of palliative care services. Quality of evidence was limited by lack of consistent approach to confounding variables as well as heterogeneity of the included studies.

CONCLUSION

Psychiatric comorbidity is associated with significant differences in care utilization and clinical outcome among patients at end of life. In particular, patients with psychiatric comorbidity and serious illness are at high risk of poor quality of life and high symptom burden. Our finding that psychiatric comorbidity is associated with increased utilization of palliative care likely reflects the complexity and clinical needs of patients with serious illness and mental health needs. These data suggest that greater integration of mental health and palliative care services may enhance quality-of-life among patients at end of life.

Hearing Aid Loan Program for Hearing Loss at the End of Life

This article describes a hearing aid loan program to provide free amplification devices for patients at the end of life to help them communicate more effectively at this critical time. It includes steps for establishing such a program, addressing challenges, and the role of the informal caregiver throughout the intervention. Healthcare professionals and social workers are encouraged to develop similar programs and use the information here as helpful suggestions to consider for their programs.

Barriers and facilitators to implementing advance care planning in naïve contexts - where to look when plowing new terrain?

BACKGROUND

Advance care planning (ACP) is a way of applying modern medicine to the principle of patient autonomy and ensuring that patients receive medical care that is consistent with their values, goals and preferences. Robust evidence supports the benefits of ACP, but it remains an underutilized resource in most countries. This paper goes from the naïve point of view, and seeks to identify the barriers and facilitators to implementation in unfamiliarized contexts and in a whole system approach involving the clinical, institutional and policy level to improve the implementation of ACP.

METHODS

Qualitative interviews were chosen to enable an explorative, flexible design. Qualitative interviews were conducted with 40 health care professionals and chief physicians in hospitals and in municipalities. The thematic analysis was done following Braun and Clarke's strategy for thematic analysis.

RESULTS

The main reported barriers were the lack of time and space, a lack of culture and leadership legitimizing ACP, lack of common communication systems, and unclear responsibility about who should initiate, resulting in missed opportunities and overtreatment. Policy development, public and professional education, and standardization of documentation were reported as key to facilitate ACP and build trust across the health care system.

CONCLUSIONS

Progressively changing the education of health professionals and the clinical culture are major efforts that need to be tackled to implement ACP in unfamiliarized contexts, particularly in contexts where patient's wishes are not legally binding. This will need to be tackled through rectifying the misconception that ACP is only about death, and providing practical training for health professionals, as well as developing policies and legislation on how to include patients and caregivers in the planning of care.