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Ratzel E, Pretzell IM, Kindler T, Weber M, Gerlach C. Patient Reported Outcome Measurement (PROM) under real-life conditions of non-curable cancer outpatients with the Integrated Palliative Outcome Scale (IPOS) and NCCN-Distress Thermometer - A mixed methods study. PEC INNOVATION 2024; 4:100264. [PMID: 38404931 PMCID: PMC10883829 DOI: 10.1016/j.pecinn.2024.100264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 01/17/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
Objective Prospective cohort study to test the real-life feasibility of longitudinal patient-reported outcome measurement PROM (Integrated Palliative Outcome Scale IPOS, and NCCN Distress Thermometer DT) required for outpatients with non-curable lung or prostate cancer in comprehensive cancer centers. Methods Assessment with paper-based IPOS and DT was observed for 15 months. We analyzed response to patients' distress (requests for supportive and palliative services) following PROM. Focus groups to comprehensively explore the user experience of patients, informal caregivers and health care professionals (HCP) supplemented the analysis. Results Ninety-seven percent (125/129) of the patients received a questionnaire once, but quarterly assessment as recommended by certification committees was achieved only in 50% and 31% of prostate and lung cancer patients. Although both instruments were well accepted, only IPOS showed a high content validity, because some patients had difficulties in understanding the DT. Patients felt comfortable with completing the PROM, and HCP found PROM helped to structure the patient encounter. Due to organizational deficiencies in the handling of the instruments and operationalization of reactions to identified distress, the referrals to supportive and palliative services were rare. Conclusion To facilitate consequences from PROM it should be a standardized intervention rather than assessment alone. Innovation The patient perspective improves the implementation of PROM under real-life clinical conditions.
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Affiliation(s)
- Eileen Ratzel
- Interdisciplinary Department of Palliative Care, III. Department of Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Langenbeckstraße 1, Geb. 407, 55131 Mainz, Germany
| | - Ina Maria Pretzell
- University Cancer Center Mainz (UCT Mainz), University Medical Center of the Johannes Gutenberg-University of Mainz, Germany
| | - Thomas Kindler
- University Cancer Center Mainz (UCT Mainz), University Medical Center of the Johannes Gutenberg-University of Mainz, Germany
| | - Martin Weber
- Interdisciplinary Department of Palliative Care, III. Department of Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Langenbeckstraße 1, Geb. 407, 55131 Mainz, Germany
| | - Christina Gerlach
- Interdisciplinary Department of Palliative Care, III. Department of Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Langenbeckstraße 1, Geb. 407, 55131 Mainz, Germany
- Department of Palliative Care, Heidelberg University Hospital, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany
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Moreno S, Mendieta CV, de Vries E, Ahmedzai SH, Rivera K, Cortes-Mora C, Calvache JA. Translation and linguistic validation of the Sheffield Profile for Assessment and Referral for Care (SPARC) to Colombian Spanish. Palliat Support Care 2024:1-10. [PMID: 38327224 DOI: 10.1017/s1478951524000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVES We aimed to translate and linguistically and cross-culturally validate Sheffield Profile for Assessment and Referral for Care (SPARC) in Spanish for Colombia (SPARC-Sp). METHODS The linguistic validation of SPARC followed a standard methodology. We conducted focus groups to assess the comprehensibility and feasibility. The acceptability was assessed using a survey study with potential users. RESULTS The comprehensibility assessment showed that additional adjustments to those made during the translation-back-translation process were required to apply SPARC-Sp in rural and low-schooled populations. It also identified the need for alternative administration mechanisms for illiterate people. The acceptability survey showed that potential users found SPARC-Sp as not only acceptable but also highly desirable. However, they desired to expand the number of items in all domains. SIGNIFICANCE OF RESULTS Beyond the semantic and conceptual validity attained through the back-translation process, actual cultural validity could be acquired thanks to the comprehensibility tests. Although extending the instrument is something potential users would like to do, it would make it less feasible to utilize the SPARC-Sp in clinical settings. Nonetheless, the instrument might benefit from the inclusion of a domain that evaluates challenges encountered when accessing the health-care system. For communities lacking literacy, alternate administration methods must also be considered.
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Affiliation(s)
- Socorro Moreno
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Cindy V Mendieta
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
- Department of Nutrition and Biochemistry, Faculty of Sciences, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Esther de Vries
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Sam H Ahmedzai
- School of Medicine, The University of Sheffield, Sheffield, UK
| | - Karen Rivera
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
| | | | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Schmidt EB, Blum D, Domeisen Benedetti F, Schlögl M, Strasser F. Tools for guiding interventions to address patient-perceived multidimensional unmet healthcare needs in palliative care: systematic literature review. BMJ Support Palliat Care 2023; 13:e1-e9. [PMID: 33177115 DOI: 10.1136/bmjspcare-2020-002495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/10/2020] [Accepted: 10/20/2020] [Indexed: 11/03/2022]
Abstract
CONTEXT The unmet needs of patients with advanced disease are indicative of the patient centredness of healthcare. By tracking unmet needs in clinical practice, palliative interventions are aligned with patient priorities, and clinicians receive support in intervention delivery decisions for patients with overlapping, complex needs. OBJECTIVE Identify tools used in everyday clinical practice for the purpose of identifying and addressing unmet healthcare needs for patients with advanced disease. METHODS We conducted PubMed and Cumulative Index of Nursing and Allied Health Literature searches to include studies published between 1 January 2008 and 21 April 2020. Three concepts were used in constructing a search statement: (1) patient need, (2) validated instrument and (3) clinical practice. 2313 citations were reviewed according to predefined eligibility, exclusion and inclusion criteria. Data were collected from 17 tools in order to understand how instruments assess unmet need, who is involved in tool completion, the psychometric validation conducted, the tool's relationship to delivering defined palliative interventions, and the number of palliative care domains covered. RESULTS The majority of the 17 tools assessed unmet healthcare needs and had been validated. However, most did not link directly to clinical intervention, nor did they facilitate interaction between clinicians and patients to ensure a patient-reported view of unmet needs. Half of the tools reviewed covered ≤3 dimensions of palliative care. Of the 17 tools evaluated, 4 were compared in depth, but all were determined to be insufficient for the specific clinical applications sought in this research. CONCLUSION A new, validated tool is needed to track unmet healthcare needs and guide interventions for patients with advanced disease.
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Affiliation(s)
- Ellie B Schmidt
- Clinic for Medical Oncology & Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - David Blum
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
| | - Franzisca Domeisen Benedetti
- Clinic for Medical Oncology & Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- School of Health Professions, Institute of Nursing, Zurich University of Applied Sciences ZHAW, Winterthur, Switzerland
| | - Mathias Schlögl
- Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
- Department of Geriatrics and Aging Research, University Hospital Zurich, Zurich, Switzerland
| | - Florian Strasser
- Clinic for Medical Oncology & Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Integrated Oncological Rehabiliation & Cancer Fatigue Clinic, Clinic Gais, Gais, Switzerland
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Snowden A, Young J, Roberge D, Schipani S, Murray E, Richard C, Lussier MT, White C. Holistic needs assessment in outpatient cancer care: a randomised controlled trial. BMJ Open 2023; 13:e066829. [PMID: 37142317 PMCID: PMC10163480 DOI: 10.1136/bmjopen-2022-066829] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
DESIGN Analyst blinded, parallel, multi-centre, randomised controlled trial (RCT). PARTICIPANTS People with confirmed diagnoses of cancer (head and neck, skin or colorectal) attending follow-up consultation 3 months post-treatment between 2015 and 2020. INTERVENTION Holistic needs assessment (HNA) or care as usual during consultation. OBJECTIVE To establish whether incorporating HNA into consultations would increase patient participation, shared decision making and postconsultation self-efficacy. OUTCOME MEASURES Patient participation in the consultations examined was measured using (a) dialogue ratio (DR) and (b) the proportion of consultation initiated by patient. Shared decision making was measured with CollaboRATE and self-efficacy with Lorig Scale. Consultations were audio recorded and timed. RANDOMISATION Block randomisation. BLINDING Audio recording analyst was blinded to study group. RESULTS 147 patients were randomised: 74 control versus 73 intervention. OUTCOME No statistically significant differences were found between groups for DR, patient initiative, self-efficacy or shared decision making. Consultations were on average 1 min 46 s longer in the HNA group (respectively, 17 m 25 s vs 15 min 39 s). CONCLUSION HNA did not change the amount of conversation initiated by the patient or the level of dialogue within the consultation. HNA did not change patient sense of collaboration or feelings of self-efficacy afterwards. HNA group raised more concerns and proportionally more emotional concerns, although their consultations took longer than treatment as usual. IMPLICATIONS FOR PRACTICE This is the first RCT to test HNA in medically led outpatient settings. Results showed no difference in the way the consultations were structured or received. There is wider evidence to support the roll out of HNA as part of a proactive, multidisciplinary process, but this study did not support medical colleagues facilitating it. TRIAL REGISTRATION NUMBER NCT02274701.
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Affiliation(s)
- Austyn Snowden
- Edinburgh Napier University, School of Nursing Midwifery and Social Care, Edinburgh, UK
| | - Jenny Young
- Edinburgh Napier University, School of Nursing Midwifery and Social Care, Edinburgh, UK
| | - Denis Roberge
- Département de médecine de famille et de médecine d'urgence, University of Quebec in Montreal, Montreal, Quebec, Canada
| | - Stefano Schipani
- Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Esther Murray
- Psychology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Claude Richard
- MEDICODE, University of Quebec in Montreal, Montreal, Quebec, Canada
| | - Marie-Therese Lussier
- Faculté de médecine - Département de médecine de famille et de médecine d'urgence, University of Montreal, Montreal, Quebec, Canada
| | - Craig White
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
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Bryk A, Roberts G, Hudson P, Harms L, Gerdtz M. The concept of holism applied in recent palliative care practice: A scoping review. Palliat Med 2023; 37:26-39. [PMID: 36333861 DOI: 10.1177/02692163221129999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Whilst there is a sense of holism existing within palliative care practice, what is not clear is the extent to which holism, as applied in recent palliative care practice, has been adequately researched. Currently, no reviews on this topic were identified through systematic and scoping review registries. AIM To identify and describe the available published evidence on the key features of holism and the core domains underpinning the application of holism in relation to recent palliative care practice. DESIGN Scoping review using the Johanna Briggs Institute design. DATA SOURCES MEDLINE, EMCARE, and CINAHL (Ovid), PsycINFO, SocINDEX, SCOPUS and Web of Science. (International, peer-reviewed, published papers in the English language from January 2010to December 2020). RESULTS Five studies met inclusion criteria. Two studies used qualitative methods, one used mixed-methods, and two were randomised controlled trials. The research investigated (1) frameworks for holistic care and (2) assessment tools applied in palliative care settings. CONCLUSIONS The results from the review led to identifying key features of palliative care that were presented as interconnected aspects of holistic care domains in both assessments and interventions. The literature revealed a focus on curative and biomedical approaches to disease management with holistic aspects acknowledged, but not in the forefront of core service delivery. Holism was generally conceptualised as an overarching theoretical framework to palliative care service provision and positioned as an adjunct to palliative models of care. These findings point to a gap in research that links the concept of holism to applied palliative care practices.
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Affiliation(s)
- Andrea Bryk
- Department of Nursing, School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Greg Roberts
- Jesuit Social Services, Support After Suicide, Melbourne, VIC, Australia
| | - Peter Hudson
- Centre for Palliative Care, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Louise Harms
- Department of Social Work, School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Marie Gerdtz
- Department of Nursing & Centre for Cancer Research, The University of Melbourne, Melbourne, VIC, Australia
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Appleton R, Nanton V, Ahmed N, Loew J, Roscoe J, Muthuswamy R, Patel P, Dale J, Ahmedzai SH. A Web-Based Prostate Cancer-Specific Holistic Needs Assessment (CHAT-P): Multimethod Study From Concept to Clinical Practice. JMIR Cancer 2022; 8:e32153. [PMID: 36260380 DOI: 10.2196/32153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 05/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Men with prostate cancer experience immediate and long-term consequences of the disease and its treatment. They require both long-term monitoring for recurrence or progression and follow-up to identify and help manage psychosocial and physical impacts. Holistic Needs Assessment aims to ensure patient-centered continuing cancer care. However, paper-based generic tools have had limited uptake within cancer services, and there is little evidence of their impact. With the expansion of remote methods of care delivery and to enhance the value of generic tools, we developed a web-based Composite Holistic Needs Assessment Adaptive Tool-Prostate (CHAT-P) specifically for prostate cancer. OBJECTIVE This paper described the context, conceptual underpinning, and approach to design that informed the development of CHAT-P, starting from the initial concept to readiness for deployment. Through this narrative, we sought to contribute to the expanding body of knowledge regarding the coproduction process of innovative digital systems with potential for enhanced cancer care delivery. METHODS The development of CHAT-P was guided by the principles of coproduction. Men with prostate cancer and health care professionals contributed to each stage of the process. Testing was conducted iteratively over a 5-year period. An initial rapid review of patient-reported outcome measures identified candidate items for inclusion. These items were categorized and allocated to overarching domains. After the first round of user testing, further items were added, improvements were made to the adaptive branching system, and response categories were refined. A functioning version of CHAT-P was tested with 16 patients recruited from 3 outpatient clinics, with interviewers adopting the think-aloud technique. Interview transcripts were analyzed using a framework approach. Interviews and informal discussions with health care professionals informed the development of a linked care plan and clinician-facing platform, which were incorporated into a separate feasibility study of digitally enhanced integrated cancer care. RESULTS The findings from the interview study demonstrated the usability, acceptability, and potential value of CHAT-P. Men recognized the benefits of a personalized approach and the importance of a holistic understanding of their needs. Preparation for the consultation by the completion of CHAT-P was also recognized as empowering. The possible limitations identified were related to the importance of care teams responding to the issues selected in the assessment. The subsequent feasibility study highlighted the need for attention to men's psychological concerns and demonstrated the ability of CHAT-P to capture red flag symptoms requiring urgent investigation. CONCLUSIONS CHAT-P offers an innovative means by which men can communicate their concerns to their health care teams before a physical or remote consultation. There is now a need for a full evaluation of the implementation process and outcomes where CHAT-P is introduced into the clinical pathway. There is also scope for adapting the CHAT-P model to other cancers.
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Affiliation(s)
- Rebecca Appleton
- Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, United Kingdom
| | - Veronica Nanton
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Nisar Ahmed
- Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Joelle Loew
- Lucerne School of Business, Lucerne, Switzerland
| | - Julia Roscoe
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | | | - Prashant Patel
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sam H Ahmedzai
- Medical School, University of Sheffield, Sheffield, United Kingdom
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7
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Richfield EW, Allgar V, Girgis A, Johnson MJ. Parkinson's disease - palliative care needs assessment tool: adaptation and psychometric testing. BMJ Support Palliat Care 2022; 12:bmjspcare-2021-003447. [PMID: 35882517 DOI: 10.1136/spcare-2021-003447] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Parkinson's disease is a progressive, life-limiting disease, which benefits from structured palliative care. Systematic recognition and triage of needs helps facilitate care, allows focused referral to specialist palliative care and aids sustainability of services. Existing palliative care tools for Parkinson's are patient/caregiver completed and focus on quantification rather than identification of the need. The Needs Assessment Tool: Progressive Disease in Cancer was designed for rapid identification of unmet needs in cancer. We describe adaptation and psychometric testing of the tool for Parkinson's disease (NAT:Parkinson's disease). METHODS Set in secondary care, Parkinson's disease outpatient clinics in the UK, this study included people with Parkinson's, age >18, including all disease stages. People with atypical Parkinsonian syndromes were excluded. Adaptation was made using systematic review and focus groups. Construct validity was tested in 50 consecutive patients against established patient and caregiver measures, analysed with Kendall's Tau B. Inter-rater reliability, using video consultations, were calculated in broad range of clinicians involved in Parkinson's disease care using a weighted kappa; 0-0.2=slight, 0.21-0.40=fair, 0.41-0.60=moderate, 0.61-0.80=substantial and p<0.05 indicative of statistically significant agreement. RESULTS Validity was substantial for two, moderate for five and fair for four constructs. Inter-rater reliability was substantial for one, moderate for three and fair for six constructs. Two constructs failing to demonstrate fair reliability did show very high percentage agreement. CONCLUSION Findings support the suitability of the NAT:Parkinson's disease for everyday clinical use in the identification and triage of unmet palliative need for people with Parkinson's disease.
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Affiliation(s)
| | - Victoria Allgar
- Peninsula Clinical Trials Unit, Plymouth University, Plymouth, UK
| | - Afaf Girgis
- South Western Sydney Clinical School, University of NSW, Sydney, New South Wales, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
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8
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King C, Khamis A, Ross J, Murtagh FEM, Johnson MJ, Ramsenthaler C. Concurrent Validity and Prognostic Utility of the Needs Assessment Tool: Progressive Disease Heart Failure. J Pain Symptom Manage 2022; 63:635-644.e3. [PMID: 35081445 DOI: 10.1016/j.jpainsymman.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
CONTEXT People with advanced heart failure have supportive and palliative needs requiring systematic assessment. OBJECTIVES We aimed to assess the validity of the Needs Assessment Tool: Progressive Disease - Heart Failure (NAT:PD-HF). METHODS Secondary analysis of routinely collected patient data from a specialist palliative care-heart disease service improvement project. NAT:PD-HF, the Integrated Palliative care Outcome Scale (IPOS), and patient and/or carer-report data were collected. Concurrent validity between NAT:PD-HF items and comparison measures (Kendall's tau; kappa); construct validity via known-group comparisons; predictive utility of NAT:PD-HF for survival (multivariable Cox hazard regression model). RESULTS Data from 88 patients (50% men; mean age 85; median survival 205 days; 64% left ventricular systolic dysfunction) were analyzed. Prevalence- and bias-adjusted kappa values indicated moderate agreement for physical symptom needs (k: 0.33 for patients, 0.42 for carers). Substantial agreement was observed for patient and/or carer psychological symptoms, and information needs (k ≥ 0.6). NAT:PD-HF distinguished between patients with different survival, comorbidities, functional scores, and palliative Phase of Illness with moderate to high effect sizes. NAT did not predict survival when adjusted for mortality risk score and functional status (2+ needs HR: 1.52, 95% CI: 1.01-1.74). CONCLUSION The NAT:PD-HF is a valid tool for clinician assessment of physical, psychosocial, and information patient and/or carer needs.
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Affiliation(s)
- Chloe King
- Wolfson Palliative Care Research Center (C.K., A.K.,F.E.M.M.,M.J.J.,C.R., Hull York Medical School, University of Hull, Hull, UK
| | - Assem Khamis
- Wolfson Palliative Care Research Center (C.K., A.K.,F.E.M.M.,M.J.J.,C.R., Hull York Medical School, University of Hull, Hull, UK
| | - Joy Ross
- St Christopher's Hospice London (J.R.), London, UK
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Center (C.K., A.K.,F.E.M.M.,M.J.J.,C.R., Hull York Medical School, University of Hull, Hull, UK; Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation (F.E.M.M.,C.R.), King's College London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Center (C.K., A.K.,F.E.M.M.,M.J.J.,C.R., Hull York Medical School, University of Hull, Hull, UK
| | - Christina Ramsenthaler
- Wolfson Palliative Care Research Center (C.K., A.K.,F.E.M.M.,M.J.J.,C.R., Hull York Medical School, University of Hull, Hull, UK; Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation (F.E.M.M.,C.R.), King's College London, London, UK; School of Health Professions, Institute of Nursing (C.R.), Zurich University of Applied Sciences, Winterthur, Switzerland.
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Assessing unmet needs in advanced cancer patients: a systematic review of the development, content, and quality of available instruments. J Cancer Surviv 2021; 16:960-975. [PMID: 34363187 PMCID: PMC9489568 DOI: 10.1007/s11764-021-01088-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/13/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Advances in treatment, including biological and precision therapies, mean that more people are living with advanced cancer. Supportive care needs likely change across the cancer journey. We systematically identified instruments available to assess unmet needs of advanced cancer patients and evaluated their development, content, and quality. METHODS Systematic searches of MEDLINE, CINAHL, Embase, PubMed, and PsycINFO were performed from inception to 11 January 2021. Independent reviewers screened for eligibility. Data was abstracted on instrument characteristics, development, and content. Quality appraisal included methodological and quality assessment, GRADE, feasibility, and interpretability, following consensus-based standards for the selection of health measurement instruments (COSMIN) guidelines. RESULTS Thirty studies reporting 24 instruments were identified. These were developed for general palliative patients (n = 2 instruments), advanced cancer (n = 8), and cancer irrespective of stage (n = 14). None focused on patients using biological or precision therapies. The most common item generation and reduction techniques were amending an existing instrument (n = 11 instruments) and factor analysis (n = 8), respectively. All instruments mapped to ≥ 5 of 11 unmet need dimensions, with Problems and Needs in Palliative Care (PNPC) and Psychosocial Needs Inventory (PNI) covering all 11. No instrument reported all of the COSMIN measurement properties, and methodological quality was variable. CONCLUSIONS Many instruments are available to assess unmet needs in advanced cancer. There is extensive heterogeneity in their development, content, and quality. IMPLICATIONS FOR CANCER SURVIVORS Given the growth of precision and biological therapies, research needs to explore how these instruments perform in capturing the needs of people using such therapies.
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Bedford LE, Yeung MHY, Au CH, Tse ETY, Yim WY, Yu EYT, Wong CKH, Lam CLK. The validity, reliability, sensitivity and responsiveness of a modified Patient Enablement Instrument (PEI-2) as a tool for serial measurements of health enablement. Fam Pract 2021; 38:339-345. [PMID: 32968812 PMCID: PMC8414911 DOI: 10.1093/fampra/cmaa102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Patient enablement is a core tenet of patient-centred and holistic primary care. The Patient Enablement Instrument (PEI) is a transitional measure limited in its ability to measure changes over time. A modified version, PEI-2, has been developed to measure enablement at a given time-point without comparison to a recalled baseline. OBJECTIVE To assess the validity, reliability, sensitivity and responsiveness of PEI-2. METHODS PEI-2 was modified from the Chinese PEI to assess enablement over 4 weeks in a prospective cohort study nested within a community support programme [Trekkers Family Enhancement Scheme (TFES)] in Hong Kong. Construct validity was assessed by factor analysis and convergent validity by Spearman's correlations with health-related quality of life and depressive symptoms. Internal reliability was assessed using Cronbach's alpha. Test-retest reliability was assessed by intraclass correlation (ICC), responsiveness by 12-24-month change in PEI-2 score and sensitivity by differences in change of PEI-2 score between TFES participants and a control group. RESULTS PEI-2 demonstrated construct validity with all items loading on one factor (factor loadings >0.7). Convergent validity was confirmed by significant correlations with 12-item Short Form Questionnaire, version 2 (r = 0.1089-0.1919) and Patient Health Questionnaire-9 (r = -0.2030). Internal reliability was high (Cronbach's alpha = 0.9095) and test-retest reliability moderate (ICC = 0.520, P = 0.506). Significant improvements in PEI-2 scores among the TFES group suggested good responsiveness (P < 0.001). The difference in change of PEI-2 scores between TFES and control was significant (P = 0.008), indicating good sensitivity. CONCLUSIONS This study supports the validity, reliability, sensitivity and responsiveness of PEI-2 in measuring changes in enablement, making it a promising tool for evaluating enablement in cohort and intervention studies.
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Affiliation(s)
- Laura Elizabeth Bedford
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Maegan Hon Yan Yeung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Chi Ho Au
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Emily Tsui Yee Tse
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Wing Yee Yim
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China.,Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
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Goni-Fuste B, Crespo I, Monforte-Royo C, Porta-Sales J, Balaguer A, Pergolizzi D. What defines the comprehensive assessment of needs in palliative care? An integrative systematic review. Palliat Med 2021; 35:651-669. [PMID: 33648403 DOI: 10.1177/0269216321996985] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters. AIM To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care. DESIGN An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool. DATA SOURCES PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020. RESULTS Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains. CONCLUSIONS The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.
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Affiliation(s)
- Blanca Goni-Fuste
- Nursing Department, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Barcelona, Spain
| | - Iris Crespo
- Department of Basic Sciences, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Cristina Monforte-Royo
- Nursing Department, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Barcelona, Spain
| | - Josep Porta-Sales
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Barcelona, Spain.,Institut Català d'Oncologia Girona, Girona, Spain
| | - Albert Balaguer
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Barcelona, Spain.,Universitat Internacional de Catalunya, Hospital Universitari General de Catalunya, Barcelona, Spain
| | - Denise Pergolizzi
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Barcelona, Spain
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Hawkins C, Kirby M, Genn H, Close H. Legal needs of adults with life-limiting illness: what are they and how are they managed? A qualitative multiagency stakeholder exercise. INTEGRATED HEALTHCARE JOURNAL 2020. [DOI: 10.1136/ihj-2019-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
ObjectiveLittle is known about legal needs in the context of life-limiting illness, particularly the need for advice concerning legal arrangements, rights and entitlements. This UK-based multiagency stakeholder engagement exercise scoped legal needs associated with life-limiting illness and identified support structures, gaps and opportunities for practice improvement.Method and analysisSnowball sampling generated a stakeholder group from a wide range of regional and national organisations involved in care of people with life-limiting illness, spanning health, social care, legal support, advice, charities, prison services as well as patient and carer representatives. A coproduced survey of three open questions generated qualitative data, interpreted by thematic analysis.ResultsStakeholders reported a broad spectrum of problems and needs raising legal issues, with no consistency of definition. A classification is proposed, identifying matters concerning rights and entitlements of patients/carers in day-to-day life and decisions around care, both immediate and in the future, as well as professional responsibilities in delivering personalised care. The support structures identified were predominantly online literature, although there was some availability of remote and face-to-face services. Limited awareness of the issues, variable service configuration, fragmentation of care and inequitable access were identified as barriers to support. Stakeholders recognised the need for education and closer multiagency working.Conclusions‘Legal needs’ incorporate wide-ranging issues, but there is inconsistency in perceptions among stakeholders. Practice is variable, risking unmet need. Opportunities for improvement include more formal integration of social welfare legal services in the health context, generating clearer pathways for assessment and management.
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Abstract
PURPOSE OF REVIEW Breathlessness is a common yet complex symptom of advanced disease. Effective management will most likely draw upon the skills of multiple disciplines and professions. This review considers recent advances in the management of chronic breathlessness with regards to interdisciplinary working. RECENT FINDINGS There are growing data on interventions for chronic breathlessness that incorporate psychosocial mechanisms of action, for example, active mind-body treatments; and holistic breathlessness services that exemplify interprofessional working with professionals sharing skills and practice for user benefit. Patients value the personalized, empathetic and understanding tenor of care provided by breathlessness services, above the profession that delivers any intervention. Workforce training, decision support tools and self-management interventions may provide methods to scale-up these services and improve reach, though testing around the clinical effects of these approaches is required. SUMMARY Chronic breathlessness provides an ideal context within which to realize the benefits of interdisciplinary working. Holistic breathlessness services can commit to a comprehensive approach to initial assessment, as they can subsequently deliver a wide range of interventions suited to needs as they are identified.
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Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials. BMC Palliat Care 2020; 19:6. [PMID: 31918702 PMCID: PMC6953282 DOI: 10.1186/s12904-019-0506-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/12/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials. METHODS A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data. RESULTS One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations. CONCLUSION Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.
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Horseman Z, Milton L, Finucane A. Barriers and facilitators to implementing the Carer Support Needs Assessment Tool in a community palliative care setting. Br J Community Nurs 2019; 24:284-290. [PMID: 31166774 DOI: 10.12968/bjcn.2019.24.6.284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Family carers play a central role in community-based palliative care. However, caring for a terminally ill person puts the carer at increased risk of physical and mental morbidity. The Carer Support Needs Assessment Tool (CSNAT) enables comprehensive assessment of carer support needs. The present study aimed to identify barriers and facilitators to implementing the CSNAT in a community specialist palliative care service. Semi-structured interviews with 12 palliative care nurse specialists from two community nursing teams in Lothian, Scotland, June 2017. Data was audio-recorded, transcribed and analysed. Palliative care nurse specialists acknowledge the importance of carers in palliative care and encourage carer support practices. Nurses perceived the CSNAT as useful, but used it as an 'add-on' to current practice, rather than as a new approach to carer-led assessment. Further training is recommended to ensure community palliative care nurses are familiar with the broader CSNAT approach.
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Affiliation(s)
- Zoe Horseman
- Research Assistant, Usher Institute of Population Health Sciences and Informatics College of Medicine and Veterinary Medicine, University of Edinburgh
| | | | - Anne Finucane
- Honorary Fellow, University of Edinburgh; Research Lead, Marie Curie Hospice
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Wilcock A, Hussain A, Maddocks M. Holistic Needs of People with Thoracic Cancer Identified by the Sheffield Profile for Assessment and Referral to Care Questionnaire ©. J Palliat Med 2019; 22:1120-1123. [PMID: 30848688 DOI: 10.1089/jpm.2018.0540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: A holistic needs assessment is recommended in people with cancer at key stages, including soon after diagnosis. For people with thoracic cancer, there is a lack of data obtained routinely at this time point. Objective: To identify the most common and/or distressing supportive and palliative needs present soon after diagnosis using a specifically developed questionnaire. Methods: As part of a local rehabilitation service, patients within three to six weeks of a diagnosis of thoracic cancer were invited to complete the Sheffield Profile for Assessment and Referral to Care (SPARC©) questionnaire. Results: For a 26-month period, 738 patients completed the questionnaire, representing about 70% of all patients diagnosed with thoracic cancer during this time. Respondents had a median [interquartile range] of 15 (11-21) symptoms or issues, with 2 (0-5), 4 (2-7), and 7 (5-11) causing "very much," "quite a bit," and "a little" distress or bother, respectively. The top five most frequent needs causing any degree of distress or bother were physical, present in 68%-80% of patients: feeling tired, shortness of breath, cough, feeling sleepy in the day, changes in weight. Two psychological issues followed: worrying about effects of the illness on others, feeling anxious, both present in 67%. Despite most patients reporting talking to health professionals about their condition, 20%-30% wanted further information. Conclusions: These findings represent the largest cohort of patients with thoracic cancer completing the SPARC questionnaire soon after diagnosis, and provide detailed information on the high level of need that thoracic oncology services must be able to respond to.
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Affiliation(s)
- Andrew Wilcock
- Department of Clinical Oncology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Asmah Hussain
- Department of Palliative Care, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Matthew Maddocks
- Department of Palliative Care, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Donnelly JP, Downing K, Cloen J, Fragen P, Gupton AW, Misasi J, Michelson K. Development and Assessment of a Measure of Parent and Child Needs in Pediatric Palliative Care. J Pain Symptom Manage 2018; 55:1077-1084.e2. [PMID: 29288879 PMCID: PMC6282185 DOI: 10.1016/j.jpainsymman.2017.12.484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Pediatric palliative care has no evidence-based needs assessment measure. The Parent and Child Needs Survey (PCNeeds) is a new instrument designed to assess the needs of children in palliative care, including children receiving end-of-life care, and their families. OBJECTIVES This study examines the psychometrics of and respondents' perceptions about the PCNeeds. METHODS Parents of children in four outpatient pediatric palliative care programs completed the PCNeeds and the World Health Organization Quality of Life-Brief tool (WHOQOL-BREF). Parents answered questions about demographics and the experience of completing the PCNeeds. Internal scale reliability was measured with Cronbach's alpha. Validity was assessed by correlating the PCNeeds total and subscale scores with the WHOQOL-BREF subscales. Additional respondent perceptions were obtained via written comments and analyzed using content analysis. RESULTS The 93 respondents were predominantly female (n = 69, 74%); white (n = 79, 85%); college graduates (n = 71, 76%); and married or partnered (n = 75, 81%). Internal reliability was acceptable (Cronbach's α = 0.83), and validity correlations with the WHOQOL-BREF subscales were consistent with theoretical expectations (moderate negative correlations ranging from -0.36 to -0.51). The most frequently cited need not addressed by our survey was sibling impact (n = 17, 18%). Twelve parents (13%) indicated that no content was missing. The least met needs were financial impact, family impact, and the child's physical problems besides pain. Sixty-eight percent of parents (n = 63) rated completion of the survey as "easy" or "very easy." CONCLUSION Initial psychometric analysis of the PCNeeds is encouraging, but further study of reliability and validity with more diverse respondents is needed.
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Affiliation(s)
| | - Kim Downing
- Greater Illinois Pediatric Palliative Care Coalition, Chicago, Illinois, USA
| | - Jason Cloen
- CompassionNet, Lifetime Care Home Health Care and Hospice, Rochester, New York, USA
| | | | - Alyssa W Gupton
- CompassionNet, Lifetime Care Home Health Care and Hospice, Rochester, New York, USA
| | - Jen Misasi
- Greater Illinois Pediatric Palliative Care Coalition, Chicago, Illinois, USA
| | - Kelly Michelson
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
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Lutz BJ, Green T. Nursing’s Role in Addressing Palliative Care Needs of Stroke Patients. Stroke 2016; 47:e263-e265. [DOI: 10.1161/strokeaha.116.013282] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 08/30/2016] [Accepted: 09/21/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Barbara J. Lutz
- From the School of Nursing, University of North Carolina–Wilmington (B.J.L.); and School of Nursing, Queensland University of Technology, Brisbane, Australia (T.G.)
| | - Theresa Green
- From the School of Nursing, University of North Carolina–Wilmington (B.J.L.); and School of Nursing, Queensland University of Technology, Brisbane, Australia (T.G.)
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Nicholson C, Morrow EM, Hicks A, Fitzpatrick J. Supportive care for older people with frailty in hospital: An integrative review. Int J Nurs Stud 2016; 66:60-71. [PMID: 28012311 DOI: 10.1016/j.ijnurstu.2016.11.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care. AIM To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation. DESIGN An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken. DATA SOURCES Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes. RESULTS Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings. CONCLUSION The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.
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Affiliation(s)
- Caroline Nicholson
- Supportive and End of Life Care (Nursing), King's College London/St. Christopher's Hospice, King's College London, Florence Nightingale Faculty of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Elizabeth M Morrow
- Research Support, Northern Ireland, Belfast, Northern Ireland BT30 9QT, United Kingdom.
| | - Allan Hicks
- City University of London, School of Health Sciences, United Kingdom
| | - Joanne Fitzpatrick
- King's College London, Florence Nightingale Faculty of Nursing and Midwifery, United Kingdom
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Pattison N, Wood J. Palliative care in cancer: the challenge for how professionals can best meet patients’ and families’ needs. Eur J Cancer Care (Engl) 2016; 25:531-3. [DOI: 10.1111/ecc.12539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - J. Wood
- Palliative Care; The Royal Marsden; London UK
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