Spiritual Care, Pain Reduction, and Preferred Place of Death Among Advanced Cancer Patients in Soweto, South Africa

South African palliative care provider perspectives on emergency medical services in palliative situations

Introduction

Due to the frequent intersection of Emergency Medical Services (EMS) with palliative situations and the increasing global need for palliative care, there has been increased recognition of the need for palliative care integration with EMS. However, EMS and palliative care systems remain segregated in many Low-to-Middle Income Country contexts, as in South Africa (SA). The aim of this study was to gather perspectives of palliative care providers in SA concerning EMS in palliative situations.

Methods

A qualitative design employing individual semi-structured interviews was implemented. Ten interviews with experienced doctors and nurses holding post-graduate palliative medicine qualifications were conducted. Verbatim transcriptions of interviews were subjected to content analysis with an inductive-dominant approach to develop codes and categories.

Results

Four categories were developed: (1) Disposition towards EMS, (2) Perceived EMS challenges, (3) Positive EMS impact across patients' palliative care journeys and (4) Methods of EMS and palliative care system integration. Participants maintained an overall positive view of EMS and palliative care integration, noting the beneficial impact of EMS and suggesting various methods of integration, while also highlighting challenges and concerns.

Conclusion

EMS and palliative care integration would be mutually beneficial to both systems while benefiting patient well-being and the broader healthcare system. Potentially low-cost, high-impact interventions suggested by participants, such as palliative care cards for patients and enhancing EMS and palliative care system communication, represent efficacious and judicious use of limited resources within the SA context. Pilot studies investigating these suggestions should be conducted.

Predicting place of death of patients with advanced cancer receiving home-based palliative care services in Iran

BACKGROUND

While home is frequently expressed as the favorite place of death (PoD) among terminally ill cancer patients, various factors affect the fulfillment of this wish. The determinants of the PoD of cancer patients in countries without healthcare system-integrated palliative and supportive care have not been studied before. This study aimed at identifying the predictors of the PoD of patients who suffer from advanced cancer by developing a reliable predictive model among who received home-based palliative care in Iran as a representative of the countries with isolated provision of palliative care services.

METHODS

In a cross-sectional study, electronic records of 4083 advanced cancer patients enrolled in the Iranian Cancer Control Center (MACSA) palliative homecare program, who died between February 2018 and February 2020 were retrieved. Multivariable binary logistic regression analysis as well as subgroup analyses (location, sex, marital status, and tumor topography) was performed to identify the predictors of PoD.

RESULTS

Of the 2398 cases included (mean age (SD) = 64.17 (14.45) year, 1269 (%52.9) male), 1216 (50.7%) patients died at home. Older age, presence and intensity of medical homecare in the last two weeks and registration in the Tehran site of the program were associated with dying at home (P < 0.05). Gynecological or hematological cancers, presence and intensity of the calls received from the remote palliative care unit in the last two weeks were predictors of death at the hospital (p < 0.05). The model was internally and externally validated (AUC = 0.723 (95% CI = 0.702-0.745; P < 0.001) and AUC = 0.697 (95% CI = 0.631-0.763; P < 0.001) respectively).

CONCLUSION

Our model highlights the demographic, illness-related and environmental determinants of the PoD in communities with patchy provision of palliative care. It also urges policymakers and service providers to identify and take the local determinant of the place of death into account to match the goals of palliative and supportive services with the patient preferences.

"I Often Just Don't Know what to Say!": Variations in Multidisciplinary Palliative Care Clinicians' Confidence and Needs Related to Spiritual Care

BACKGROUND

Spiritual care is a core component of high-quality palliative care, yet gaps exist in spiritual care provision. Understanding clinicians' levels of confidence around spiritual care and their perceptions of necessary knowledge/skills to enhance their ability to provide spiritual care is foundational for improving delivery of spiritual care in practice.

OBJECTIVES

To understand confidence levels with providing spiritual care and perceived needs in relation to the provision of spiritual care among palliative clinicians (nurses, social workers, chaplains).

DESIGN

N = 260 clinicians participating in interprofessional communication and end-of-life care training programs completed a structured survey.

MEASUREMENTS

Clinicians responded to 42 closed-ended questions assessing their confidence in engaging in spiritual care across 6 dimensions, and one open-ended question: "What areas of knowledge or skill would best help to improve your ability to provide spiritual care across diverse populations?"

RESULTS

Findings reveal varied levels of confidence with spiritual care across dimensions. Chaplains reported the highest levels of confidence compared with nurses and social workers. Key areas of knowledge/skills to improve spiritual care provision were: (1) Training and support for clinicians in spiritual care; (2) Strategies for providing spiritual care to patients from diverse cultural and/or religious backgrounds; (3) Better understanding of specific populations and contexts that may affect spiritual care provision; and (4) Clinicians' personal growth & practices to improve spiritual care.

CONCLUSIONS

Additional support with spiritual care provision is needed, especially among spiritual care generalists. A focus on culturally attuned care is needed, honoring unique patient contexts and centering patient and family priorities.

Effects of non-pharmacological interventions on pain in wound patients during dressing change: A systematic review

BACKGROUND

Changes to the wound dressing frequently cause pain. Some adverse side effects of pharmacologic pain management may cause problems or even impede wound healing. There is no systematic study of non-pharmacologic therapies for pain during wound dressing changes, despite the gradual promotion of non-pharmacologic pain reduction methods.

OBJECTIVES

To give clinical wound pain management a new direction, locating and assessing non-pharmacological interventions regarding pain brought on by wound dressing changes are necessary.

METHOD

The researchers conducted a comprehensive literature review on non-pharmacological interventions for pain during wound dressing changes across five databases: PubMed, Web of Science, Medline, Embase, and the Cochrane Library spanning the period from January 2010 to September 2022. The evaluation of literature and data extraction was carried out independently by two researchers, and in cases of disagreement, a third researcher participated in the deliberation. To assess the risk of bias in the literature, the researchers utilised the Cochrane Handbook for Reviews of Interventions, version 5.1.0.

RESULTS

In total, 951 people were involved in 11 investigations covering seven non-pharmacological therapies. For pain triggered by dressing changes, virtual reality (VR) distraction, auditory and visual distractions, foot reflexology, religious and spiritual care, and guided imaging demonstrated partially positive effects, with hypnosis therapy and jaw relaxation perhaps having a weak effect.

CONCLUSION

The key to managing wounds is pain management. According to our review, there is some indication that non-pharmacologic interventions can help patients feel less discomfort when having their wound dressings changed. However, the evidence supporting this view is weak. It needs to be corroborated by future research studies with multicentre and large samples. To promote and use various non-pharmacologic interventions in the future, it is also necessary to build standardised and homogenised paths for their implementation.

Barriers to optimal management of cancer pain in sub-Saharan Africa: a scoping review

Background

Although cancer is a significant issue in sub-Saharan Africa, and cancer pain is prevalent, there is insufficient data and research on the barriers to cancer pain management. Even in countries where evidence exists, few studies explore the links between these barriers, which makes it difficult to implement system-wide approaches to address them.

Methods

The search strategy was developed and conducted on databases including MEDLINE, Embase and Web of Science to identify peer-reviewed studies. Then, these retrieved studies were screened systematically to select papers that had met pre-specified criteria. The barriers were categorised into patient-, health professional- and health system-level domains. Then, the quality of the included papers was assessed using the mixed methods appraisal tool. Finally, a narrative synthesis was utilised to summarise the findings.

Results

Fourteen relevant articles from 19 sub-Saharan African countries were included in the scoping review. All the studies highlighted barriers to optimal cancer pain management. Healthcare system-related domains had the most frequently reported barriers. Approximately half of the included studies met 100% of the methodological quality criteria in the critical appraisal.

Conclusion

Improving pain management for cancer patients in sub-Saharan Africa requires further high-level research evidence on regulatory policies and interventional strategies, especially at the health system level, as most barriers to cancer pain treatment essentially stem from the healthcare system.

Benefits of Spiritual and Religious Support in the Pain Management of Cancer Patients: A Literature Scoping Review

Pain is one of the main symptoms of cancer and the most difficult to control due to its complexity as it can involve physical, psychological, social, and spiritual aspects. We proposed to summarize the scientific knowledge already published related to the influence of spirituality on pain therapy in cancer patients. Articles were searched in PubMed, SciELO, SciFinder, PsycInfo, and ScienceDirect databases using the following descriptors: "Spirituality," "Religion," "Religion," "Chronic Pain," "Pain Management" and "Cancer." A total of 68 articles were included and discussed. Most articles dealt with the influence of spirituality in palliative care, focussed on patient quality, and highlighted the importance of integrative oncology. Although few studies associated spirituality with chronic pain, most articles reported that spirituality could confer greater pain control.

Quality of Dying and Death of Patients With Cancer in Hospice Care in Uganda

PURPOSE

Despite advances in palliative care in Uganda, there has been relatively little recent patient-centered research investigating end-of-life outcomes in this region. We assessed the quality of dying and death of patients with cancer in hospice care in Uganda.

METHODS

Bereaved caregivers of patients who received hospice care in Uganda and died 2-12 months earlier (N = 201) completed the Quality of Dying and Death Questionnaire, which includes 31 items and single-item ratings of overall quality of dying and moment of death, and the FAMCARE measure of family satisfaction with cancer care.

RESULTS

Caregivers reported low-intermediate overall quality of dying (mean [M] standard deviation [SD], 3.25 [2.98]) and overall quality of moment of death (M [SD], 3.59 [3.51]), with 47.0% of the ratings of these two outcomes in the poor range, but the mean family satisfaction with care was high (M [SD], 77.75 [10.26]). Most Quality of Dying and Death Questionnaire items (74.2%) were rated within the intermediate range. Items rated within the good range were religious-spiritual, interpersonal, and personal facets; two items within the poor range reflected physical functioning. Overall quality of dying was most strongly correlated with pain control (Spearman's rho [r_s] = 0.45, P < .001), and overall quality of moment of death with state of consciousness before death and being unafraid of dying (r_s = 0.42, P < .001). The FAMCARE score was not correlated with overall quality of dying or moment of death (P = .576-.813). Only one FAMCARE item, information on managing patient's pain, was correlated with overall quality of moment of death (r_s = -0.19, P = .008).

CONCLUSION

End-of-life care in hospices in Uganda requires further improvement, particularly with regard to symptom control. Patient-centered data could bolster advocacy efforts to support quality improvement of palliative care in this and other countries.

Quality of life among patients with cancer and their family caregivers in the Sub-Saharan region: A systematic review of quantitative studies

Guided by the World Health Organization quality of life (WHOQOL) framework, this systematic review aimed to examine evidence about the prevalence and severity of QOL-related health problems and their influencing factors in Sub-Saharan Africa (SSA). We identified eligible publications in English language from PubMed, Cumulative Index of Nursing and Allied Health Literature Plus with Full Text, Embase, APA PsycInfo, Scopus, and African Index Medicus databases. We included quantitative descriptive studies that measured overall and subdomains of QOL as the outcome in adult patients/survivors with cancer in SSA. Twenty-six descriptive cross-sectional studies (27 papers) that were conducted since 1988 in different SSA countries among patients with various types of cancer met our inclusion criteria. We found inconsistencies in how the prevalence and severity of QOL-related health problems have been researched and reported across studies, which complicated comparing findings and drawing conclusions. The most common factors that influenced the overall and subdomains of QOL included coping; internal and external locus of control; symptoms and symptom management; and religious beliefs and religious care. Demographics (e.g., age and marital status), cancer-related factors (cancer stage and type of treatment), and social determinants of health (e.g., education, access to information and resources, financial distress, and urban vs rural residency) also impacted QOL and its subdomains. Our findings indicate the significant need for recognizing and managing QOL-related problems for cancer patients and caregivers in SSA. Research needs to use culturally adapted, standardized assessment tools and analysis approaches to better understand the QOL challenges this population faces. Comprehensive supportive care is needed to address the complex QOL issues in resource-limited SSA.

The psychological health of patients diagnosed with cancer in Iraq during the COVID-19 pandemic: A single center study

OBJECTIVE

The objective of this study was to assess the psychological health status of patients diagnosed with cancer in Iraq during the COVID-19 pandemic. The study aim was to measure the prevalence of depression, anxiety, and stress among patients diagnosed with cancer. Secondary aims were to assess the association between depression, anxiety, and stress with sociodemographic characteristics, cancer-specific characteristics, patients' experience in healthcare visit, risk perception towards COVID-19, and health concern during the outbreak.

METHODS

A cross-sectional study was conducted between September 1, 2020 and December 1, 2020 at an Oncology clinic in Baghdad. Included in the study were two hundred patients diagnosed with cancer. Data collected included: demographic variables (age, gender, residential location, marital status, education, employment status), clinical characteristics and cancer-specific parameters (duration since cancer diagnosis, cancer type, treatment duration, clinic visits frequency), experience during the pandemic (skipping or postponing treatment or periodical tests, suffering from new body pain, fear of acquiring the infection, fear of health deterioration), as well as psychological health status (depression, anxiety, stress). Pain, risk perception towards COVID-19, and health concern were measured using categorical Likert scale with responses being no, sometimes, and often. The psychological health status was measured by the "Depression, Anxiety, and Stress Scale" (DASS-21). Cut-off scores of the DASS-21 greater than 9, 7, and 14 represent a positive screen of depression, anxiety, and stress, respectively.

RESULTS

The prevalence of patients who screened positive for depression was 22.0%, anxiety 22.0%, and stress 13.5%. The prevalence of depression, anxiety and stress were significantly more in those who had university or higher education (34.3%, p-value <0.0001; 32.3%, p-value <0.0001; 19.2%, p-value = 0.02 respectively). Those were four times more likely to have depression and two times more likely to have anxiety than participants who had school education (OR = 4.40 CI [1.98-9.77], p-value <0.0001; OR = 2.55 CI [1.15-5.65], p-value = 0.02, respectively). The prevalence of anxiety was significantly the highest in the age group 16-39 years (40.9%) compared to 22.3% in the age group 40-64 years and 10.3% in the group ≥65 years (p-value = 0.02). Patients ≥65 years of age were less likely to develop anxiety compared to younger patients (OR = 0.44 CI [0.22-0.89], p-value = 0.02). As for the patients' experience in healthcare visit, 66 patients (33.0%) skipped or postponed their treatment or tests due to the outbreak. Around (8%) sometimes suffered from new body pain. Those who sometimes suffered from new body pain had significantly more depression than patients who did not suffer new pain or often had new pain (50.0% vs. 15.0% vs. 28.1% respectively, p-value = 0.002). Those were two times more likely to be depressed (OR = 2.18 CI [1.29-3.68], p-value = 0.003). Around (50%) of the patients were often afraid that their health would deteriorate during the outbreak. Those were significantly more depressed (31.7%, p-value = 0.002), anxious (30.7%, p-value <0.0001) and stressed (21.8%, p-value = 0.002) than those who did not have fear of losing their health and were two times more likely to have anxiety and stress.

CONCLUSION

These findings, especially the association between developing new pain and depression, raised concerns regarding the psychological health in patients diagnosed with cancer during COVID-19 pandemic. It is crucial to implement psychological health screening for patients diagnosed with cancer during the pandemic to help prevent any psychological health problems. The DASS-21 could be used as a screening tool for distress in these patients.

Spiritual Care: Motivations and Experiences through the Lenses and Voices of a Cohort of Spiritual Care Workers at an Established Hospice in Cape Town, South Africa

While palliative care is beginning to gain prominence in South Africa, spiritual care remains less understood. Spiritual care is less prioritised and, consequently, this service, if offered, is mostly entrusted to volunteers. It therefore becomes prudent to understand who these volunteers are, what motivates them to volunteer, and how they see spiritual care being sustainable in the future. A cohort of spiritual care workers from a prominent hospice in Cape Town, South Africa, participated in this qualitative study. The participants made suggestions about formalising spiritual care as well as making a call for a basic entry requirement into spiritual care work.

Ethical Dilemma: Healthcare Surrogate Refusal of Opioid Administration

It is morally distressing when a healthcare provider sees patients with undertreated pain but is unable to provide adequate relief because of a surrogate's refusal of such treatment. This issue might occur when there is no clear advanced directive that represents patients' wishes for treatment, and can be further complicated when patients are of minority cultural backgrounds. This article presents a case where the surrogate of a Korean-American woman with severe somatic pain from metastatic pancreatic cancer requested only acetaminophen be given to control the patient's pain. The ethical issues associated with surrogate misconceptions on therapeutic use of opioids are reviewed. This case highlights the ethical dilemma of withholding opioid treatment in a patient with advanced cancer. We conclude that the obligation to treat pain should be understood beyond the authority of surrogate refusal, in favor of patient quality of life, when an advance directive is not in place.

What constitutes a palliative care need in people with serious illnesses across Africa? A mixed-methods systematic review of the concept and evidence

BACKGROUND

Clarity on what constitutes a palliative care need is essential to ensure that health systems and clinical services deliver an appropriate response within Universal Health Coverage.

AIM

To synthesise primary evidence from Africa for palliative care needs among patients and families with serious illness.

DESIGN

We conducted a mixed methods systematic review with sequential synthesis design. The protocol was registered with PROSPERO (CRD42019136606) and included studies were quality assessed using Mixed Method Appraisal Tool.

DATA SOURCES

Six global literature databases and Three Africa-specific databases were searched up to October 2020 for terms related to palliative care, serious illnesses and Africa. Palliative care need was defined as multidimensional problems, symptoms, distress and concerns which can benefit from palliative care.

RESULTS

Of 7810 papers screened, 159 papers met eligibility criteria. Palliative care needs were mostly described amongst patients with HIV/AIDS (n = 99 studies) or cancer (n = 59), from East (n = 72) and Southern (n = 89) Africa. Context-specific palliative care needs included managing pregnancy and breastfeeding, preventing infection transmission (physical); health literacy needs, worry about medical bills (psychological); isolation and stigma, overwhelmed families needing a break, struggling to pay children's school fees and selling assets (social and practical needs); and rites associated with cultural and religious beliefs (spiritual).

CONCLUSIONS

Palliative care assessment and care must reflect the context-driven specific needs of patients and families in Africa, in line with the novel framework. Health literacy is a crucial need in this context that must be met to ensure that the benefits of palliative care can be achieved at the patient-level.

Quality of life and associated factors among adults living with cancer and their family caregivers

This study examined the association of needs, health literacy, and quality of life among adult Nigerians with cancer and family caregivers. A descriptive study was conducted involving 240 adults with cancer and family caregivers attending a tertiary hospital. More than two-thirds of participants reported moderate or high needs. Information (90.8%) and spiritual support (85%) were the domains of highest need among adults with cancer. Family/social support (85%) and spiritual support (81.7%) ranked the highest among family caregivers. A negative correlation was found between needs and quality of life. Stepwise regression analysis showed that needs and literacy explained 36% of the variance in adults with cancer's quality of life and 28% of the variance in family caregivers' quality of life. Spiritual need accounted l for 9.5% and 9.1% of variation for adults with cancer and family caregivers, respectively. Findings suggest that interventions with a focus on social/family and spiritual needs may improve wellbeing of adults with cancer and caregivers in Nigeria. This research are generalizable to other low-income countries where family values and spirituality are often a strong feature of daily life.

Where Do Cancer Patients in Receipt of Home-Based Palliative Care Prefer to Die and What Are the Determinants of a Preference for a Home Death?

Understanding the preferred place of death may assist to organize and deliver palliative health care services. The study aims to assess preference for place of death among cancer patients in receipt of home-based palliative care, and to determine the variables that affect their preference for a home death. A prospective cohort design was carried out from July 2010 to August 2012. Over the course of their palliative care trajectory, a total of 303 family caregivers of cancer patients were interviewed. Multivariate regression analysis was employed to assess the determinants of a preferred home death. The majority (65%) of patients had a preference of home death. The intensity of home-based physician visits and home-based personal support worker (PSW) care promotes a preference for a home death. Married patients, patients receiving post-graduate education and patients with higher Palliative Performance Scale (PPS) scores were more likely to have a preference of home death. Patients reduced the likelihood of preferring a home death when their family caregiver had high burden. This study suggests that the majority of cancer patients have a preference of home death. Health mangers and policy makers have the potential to develop policies that facilitate those preferences.