Some issues in the provision of adult bereavement support by UK hospices

Using the Delphi technique to achieve consensus on bereavement care in palliative care in Europe: An EAPC White Paper

BACKGROUND

The WHO definition of palliative care includes bereavement support as integral to palliative care, yet a previous survey of bereavement support in palliative care in Europe has shown a range of service responses to loss. A rigorous approach to agreeing and implementing a palliative care bereavement framework was required.

AIM

The aim of this study was to develop consensus on best-practice recommendations for bereavement care principles, structures, processes and delivery based on current practice and evidence.

DESIGN

In accordance with Guidance on Conducting and Reporting Delphi Studies, a consensus-building five-round Delphi technique was performed. A scoping review of research literature informed drafting of 54 statements by the EAPC Bereavement Task Force. Evaluation of the statements was performed by an expert panel using a 5-point Likert scale. ⩾80% agreement were defined as essential items and 75%-79% agreement were defined as desirable items. Items with a consensus rating <75% were revised during the process.

SETTING/PARTICIPANTS

The Delphi study was carried out by an expert panel among membership organisations of the European Association for Palliative Care.

RESULTS

In total, 376 email requests to complete Delphi questionnaire were distributed with a response rate of 23% (n = 87) and a follow-up response-rate of 79% (n = 69). Of the initial 54 statements in six dimensions, 52 statements were endorsed with 26 essential statements and 26 desirable statements.

CONCLUSIONS

The six dimensions and 52 statements agreed through this Delphi study clarify a coherent direction for development of bereavement services in palliative care in Europe.

Developing Unique Insights From Narrative Responses to Bereaved Family Surveys

CONTEXT

Although bereaved family surveys (BFS) are routinely used quantitatively for quality assessment, open-ended and narrative responses are rarely systematically analyzed. Analysis of narrative responses may identify opportunities for improving end-of-life (EOL) care delivery.

OBJECTIVES

To highlight the value of routine and systematic analysis of narrative responses and to thematically summarize narrative responses to the BFS of Veterans Affairs.

METHODS

We analyzed more than 4600 open-ended responses to the BFS for all 2017 inpatient decedents across Veterans Affairs facilities. We used a descriptive qualitative approach to identify major themes.

RESULTS

Thematic findings clustered into three domains: patient needs, family needs, and facility and organizational characteristics. Patient needs include maintenance of veteran's hygiene, appropriately prescribing medications, adhering to patient wishes, physical presence in patient's final hours, and spiritual and religious care at EOL. Family and caregiver needs included enhanced communication with the patient's care team, assistance with administrative and logistical challenges after death, emotional support, and displays of respect and gratitude for the patient's life. Facility and organizational characteristics included care team coordination, optimal staffing, the importance of nonclinical staff to care, and optimizing facilities to be welcoming, equipped for individuals with disabilities, and able to provide high-quality food.

CONCLUSION

Systematic analysis of narrative survey data yields unique findings not routinely available through quantitative data collection and analysis. Organizations may benefit from the collection and regular analysis of narrative survey responses, which facilitate identification of needed improvements in palliative and EOL care that may improve the overall experiences for patients and families.

The impacts and effectiveness of support for people bereaved through advanced illness: A systematic review and thematic synthesis

BACKGROUND

Bereavement support is a key component of palliative care, with different types of support recommended according to need. Previous reviews have typically focused on specialised interventions and have not considered more generic forms of support, drawing on different research methodologies.

AIM

To review the quantitative and qualitative evidence on the effectiveness and impact of interventions and services providing support for adults bereaved through advanced illness.

DESIGN

A mixed-methods systematic review was conducted, with narrative synthesis of quantitative results and thematic synthesis of qualitative results. The review protocol is published in PROSPERO ( www.crd.york.ac.uk/prospero , CRD42016043530).

DATA SOURCES

The databases MEDLINE, Embase, PsycINFO, CINAHL and Social Policy and Practice were searched from 1990 to March 2019. Studies were included which reported evaluation results of bereavement interventions, following screening by two independent researchers. Study quality was assessed using GATE checklists.

RESULTS

A total of 31 studies were included, reporting on bereavement support groups, psychological and counselling interventions and a mix of other forms of support. Improvements in study outcomes were commonly reported, but the quality of the quantitative evidence was generally poor or mixed. Three main impacts were identified in the qualitative evidence, which also varied in quality: 'loss and grief resolution', 'sense of mastery and moving ahead' and 'social support'.

CONCLUSION

Conclusions on effectiveness are limited by small sample sizes and heterogeneity in study populations, models of care and outcomes. The qualitative evidence suggests several cross-cutting benefits and helps explain the impact mechanisms and contextual factors that are integral to the support.

The meaning and experience of bereavement support: A qualitative interview study of bereaved family caregivers

Objective:

Experiences of bereavement can be stressful and are frequently complicated by emotional, familial, and financial issues. Some—though not all—caregivers may benefit from bereavement support. While considered standard within palliative care services in Australia, bereavement support is not widely utilized by family caregivers. There is little research focused on the forms of bereavement support desired or required by family caregivers, how such care is viewed, and/or how bereavement support is experienced. This study examined the experiences of bereaved family caregivers and their impressions of and interactions with bereavement support.

Method:

This paper reports on one aspect of a broader study designed to explore a range of experiences of patients and caregivers to and through palliative care. Focusing on experiences of bereavement, it draws on qualitative semistructured interviews with 15 family caregivers of palliative care patients within a specialist palliative care unit of an Australian metropolitan hospital. The interviews for this stage of the study were initiated 3–9 months after an initial interview with a family caregiver, during which time the palliative patient had died, and they covered family caregivers' experiences of bereavement and bereavement support. Interviews were digitally audiotaped and transcribed in full. A thematic analysis was conducted utilizing the framework approach wherein interview transcripts were reviewed, key themes identified, and explanations developed.

Results:

The research identified four prevalent themes: (1) sociocultural constructions of bereavement support as for the incapable or socially isolated; (2) perceptions of bereavement support services as narrow in scope; (3) the “personal” character of bereavement and subsequent incompatibility with formalized support, and (4) issues around the timing and style of approaches to being offered support.

Significance of results:

Systematic pre-bereavement planning and careful communication about the services offered by palliative care bereavement support centers may improve receipt of support among bereaved family caregivers in need.

"It still haunts me whether we did the right thing": a qualitative analysis of free text survey data on the bereavement experiences and support needs of family caregivers

Background

Research suggests that there may be bereavement experiences and support needs which are specific to family caregivers providing end of life care (EoLC), although this remains an under-researched area. This paper focuses on themes relating to bereavement which were derived from an analysis of free text survey responses collected in a research priority setting exercise for palliative and EoLC.

Methods

The priority setting exercise involved a public survey, designed to generate research priorities. Rather than identify research topics, many people instead described their experiences and raised more general questions relating to palliative and end of life care. To explore these experiences and perspectives a supplementary thematic analysis was conducted on the survey responses. 1403 respondents took part, including patients, current and bereaved carers, health and social care professionals, volunteers and members of the public.

Results

Several grief issues were identified, which seem specific to the experiences of family caregivers. Responses demonstrated a relationship between death experiences, feelings of guilt and bereavement outcomes for some family caregivers, as well as caregiver experiences of a “void” created by the withdrawal of professional support after death. Communication and support needs were also identified by participants.

Conclusion

This analysis provides further evidence of some of the specific effects that caring for a loved one at the end of life can have on bereavement experiences. Finding ways of improving communication around the time of death and effective follow up approaches post death could help to address some of these issues.

Nationwide survey on volunteers' training in hospice and palliative care in Poland

BACKGROUND

Volunteers working in hospice and palliative care facilities in Poland undertake various activities which are performed in accordance with legal regulations and the individual policies of each hospice. The aim of this study was to explore the roles and training of volunteers working in hospice and palliative care settings.

METHODS

A cross-sectional survey was carried out that investigated the services performed by volunteers and their preparation for work within residential hospices. Questionnaires were distributed to volunteers and hospice representatives, and the responses obtained underwent statistical analysis.

PARTICIPANTS

A total of 180 volunteers and 28 hospice representatives from 29 residential hospices participated in this survey.

RESULTS

All hospices surveyed were supported by volunteers. 79% of volunteers worked alongside patients and performed the following services: accompanying patients (76%), feeding patients (61%), cleaning rooms (48%), dressing and bathing (42%) and organising leisure time (40%). Fewer volunteers were involved in activities outside of patient support-for example, charity work and fundraising (34%), cleaning hospice buildings (23%) as well as providing information and education (22%). According to volunteers, prior to undertaking their duties, 64% participated in theoretical training and 37% took part in a practical course. The majority attended courses relating to general knowledge of hospice and palliative care (64%) and volunteer rights and duties (55%).

CONCLUSIONS

Overall, proper training was an essential requirement needed to be fulfilled by volunteers, particularly when involved in direct patient support. Most volunteers were simultaneously involved in various areas of service; therefore, their training should be comprehensive.

Building Community Capacity in Bereavement Support

Background:

Most bereaved people do not require specialist intervention, yet building community capacity in providing bereavement support is underdeveloped. While family caregivers indicate a need for more information about bereavement, there is little evidence to guide what this information might contain.

Objective:

The study’s purpose was to inform bereavement support by determining the advice people bereaved through expected deaths in palliative care have for others in that situation.

Design:

Four funeral providers posted a questionnaire to previous clients who had used their services 6 to 24 months prior and 678 bereaved people responded.

Setting/Participants:

The sample size for this study comprised 265 bereaved people whose relative used palliative care services.

Measurements:

The questionnaire comprised 82 questions about caregiving, bereavement support, current bereavement-related distress, and 2 open-ended questions concerning their bereavement, one of them on advice they have to other people in the same situation.

Results:

Family caregivers (n = 140) of people who received palliative care responded to the open-ended question about advice for others. An open content analysis yielded 3 themes—preparations for bereavement, utilizing social networks, and strategies for dealing with grief.

Conclusions:

Bereaved family caregivers’ experiential knowledge can be harnessed to progress the development of bereavement care strategies for the good of the community. These responses could be incorporated into information brochures, posters, and other community education avenues in order to upskill palliative care bereavement volunteers and the wider community so that bereaved family caregivers are best supported.

Exploring barriers to assessment of bereavement risk in palliative care: perspectives of key stakeholders

Background

Palliative care standards advocate support for grieving caregivers, given that some bereaved people fail to integrate their loss, experience ongoing emotional suffering and adverse health outcomes. Research shows that bereavement support tends to be delivered on an ad hoc basis without formal assessment of risk or need. To align support with need, assessment of bereavement risk is necessary. The overall aim is to develop a bereavement risk assessment model, based on a three-tiered public health model, congruent with palliative care bereavement standards for use in palliative care in Western Australia. The specific aim of this phase of the study was to explore the perspectives of key stakeholders and to highlight issues in relation to the practice of bereavement risk assessment in palliative care.

Methods

Action research, a cyclical process that involves working collaboratively with stakeholders, was considered as the best method to effect feasible change in practice. The nine participants were multidisciplinary health professionals from five palliative care services, and a bereaved former caregiver. Data were obtained from participants via three 90 min group meetings conducted over five weeks. An inductive thematic analysis approach was used to analyse data following each meeting until saturation was reached, and the research team was satisfied that the themes were congruent with research aims.

Results

Existing measures were found unsuitable to assess bereavement risk in palliative care. Assessment following the patient’s death presented substantial barriers, directing assessment to the pre-death period. Four themes were identified relating to issues in need of consideration to develop a risk assessment model. These were systems of care, encompassing logistics of contact with caregivers; gatekeeping; conflation between caregiver stress, burden and grief; and a way forward.

Conclusions

These group discussions provide a data-driven explanation of the issues affecting bereavement risk assessment in palliative care settings. A number of barriers will need to be overcome before assessment can become routine practice. We recommend the development of a brief, pre-death caregiver self-report measure of bereavement risk that may empower caregivers, lead to early intervention, and allow staff to remain focused on patient care, reducing burden on staff and palliative care services.

A scoping review of bereavement risk assessment measures: Implications for palliative care

BACKGROUND

Palliative care standards and policies recommend that bereavement support be provided to family caregivers, yet uncertainty surrounds whether support currently offered by palliative care services throughout developed countries meets caregiver needs. The public health model of bereavement support, which aligns bereavement support needs with intervention, may address this gap between policy and practice.

AIM

The aim was to review the literature to identify bereavement risk assessment measures appropriate for different points in the caring and bereavement trajectories, evaluate their psychometric properties and assess feasibility for use in palliative care.

DESIGN

A scoping review was systematically undertaken following Arksey and O'Malley's methodological framework.

DATA SOURCES

PsycINFO, CINAHL, PubMed and Cochrane Reviews databases, as well as grey literature including Internet searches of Google, World Health Organization, CareSearch, the Grey Literature Report and OAIster were searched. Bereavement organisations and palliative care websites, reference lists in obtained articles and grief and bereavement handbooks were also scrutinised.

RESULTS

Of 3142 records screened, 356 records yielded 70 grief measures. In all, 19 measures published between 1982 and 2014 were identified for inclusion in this review, and categorised for use with family caregivers at three points in time - before the patient's death (n = 5), in the period following the death (n = 10) and for screening of prolonged or complex grief (n = 4). The majority had acceptable psychometric properties; feasibility for use in palliative care varied substantially.

CONCLUSION

This review is an important preliminary step in improving the assessment of bereavement risk and, consequently, better bereavement outcomes for palliative care family caregivers.

Ageing prisoners' views on death and dying: contemplating end-of-life in prison

Rising numbers of ageing prisoners and goals on implementing equivalent health care in prison raise issues surrounding end-of-life care for prisoners. The paucity of research on this topic in Europe means that the needs of older prisoners contemplating death in prison have not been established. To investigate elderly prisoners' attitudes towards death and dying, 35 qualitative interviews with inmates aged 51 to 71 years were conducted in 12 Swiss prisons. About half of the prisoners reported having thought about dying in prison, with some mentioning it in relation with suicidal thoughts and others to disease and old age. Themes identified during data analysis included general thoughts about death and dying, accounts of other prisoners' deaths, availability of end-of-life services, contact with social relations, and wishes to die outside of prison. Study findings are discussed using Allmark's concept of "death without indignities," bringing forth two ethical issues: fostering autonomy and removing barriers. Attributing the identified themes to these two ethical actions clarifies the current needs of ageing prisoners in Switzerland and could be a first step towards the implementation of end-of-life services in correctional systems.

Existential behavioral therapy for informal caregivers of palliative patients: Barriers and promoters of support utilization

Objective:

Several interventions have been developed during recent years to support informal caregivers of palliative patients. However, these trials reported low enrollment rates. Employing a newly developed group intervention, existential behavioral therapy (EBT), one study reported that only 13.6% of approached informal caregivers participated. The purpose of our present study was to identify the reasons for this low enrollment rate in order to improve future support designs.

Method:

All participants in the EBT trial (intervention vs. standard-care control group) as well as those who declined participation during a 4-month recruitment period were studied prospectively over 12 months. Andersen's behavioral model of healthcare service use was employed to identify group differences between acceptors and decliners: predisposing (age, gender, education, family status, relationship), enabling (social support, distance to hospital, caring vs. bereaved), and need factors (psychological distress, quality of life) were evaluated in a binary-logistic model.

Results:

Some 94 decliners were compared to 160 EBT participants (n = 81 intervention, n = 79 control). Caregivers who took part were significantly more distressed and suffered from a lower quality of life compared to decliners. Not only these need factors but also predisposing (age <55 years) and enabling (use of social/professional support, familiarity with caregiving institution) factors were associated with EBT utilization. At the 12-month follow-up, EBT intervention participants reported greater quality of life improvements than decliners or controls (p = 0.05). While all groups had mean anxiety scores below the cutoff at 12-month follow-up, decliners showed better improvement in anxiety compared to EBT participants (intervention p = 0.04, controls p = 0.03).

Significance of results:

On average, decliners are less burdened: they may be more resilient, may have better coping strategies, or already have a sufficient support network in place. Screening caregivers with regard to their experienced quality of life and targeting those in need, especially younger caregivers with low levels of quality of life, may help to allocate resources more appropriately.

Helpful aspects of bereavement support for adults following an expected death: volunteers' and bereaved people's perspectives

Helpful and unhelpful aspects of bereavement support were investigated from the perspectives of 24 bereaved adults and their volunteer bereavement support workers. Most commonly reported themes were the provision of hope and reassurance, and the opportunity for continued sharing and support. Significantly more clients than volunteers reported provision of information, and talking to someone outside their social network as helpful, and both groups scored higher on helpfulness ratings than comparative groups of psychotherapists and clients. Clients' grieving styles and the quality of the helping relationship were also related to what was seen as helpful.

Bereavement care for older people in healthcare settings: qualitative study of experiences

AIM

This study aimed to explore the experiences of healthcare staff of caring for bereaved older people, and older people's experiences of bereavement care.

BACKGROUND

Loss through death of close family members, partners and friends inhibits the physical, emotional and social well being of older people. The rising population of older people and pressure on healthcare services to reduce costs indicate the necessity of developing strategies that enable coping and independence.

DESIGN

A qualitative design drawing on phenomenological methodology was used to understand interactions between healthcare staff and bereaved older people. The study was set in hospital wards, general practice and community nursing teams, and care homes. Healthcare staff and a sample of recently bereaved older people participated.

METHODS

Purposive sampling took place to recruit staff with a range of roles, and older people who were 65 years of age or more, and bereaved of a family member or friend for between 6 months and 5 years. Participants took part in in-depth interviews, and data were analysed systematically.

RESULTS

Thirty-nine participants were recruited, and three key themes arose from the data: (i) Bereavement care depends on an established relationship between healthcare staff and the patient's relatives; (ii) Preparation for the relative's death may not equate to being prepared for bereavement; (iii) The 'Open Door' to bereavement care is only slightly ajar.

CONCLUSIONS

The study identified the interactions of healthcare staff with bereaved older people in terms of the bereavement journey. Staff demonstrated awareness of difficulties the bereaved person may encounter and showed commitment to providing support. However, lack of flexibility in services restricts meaningful interactions.

IMPLICATIONS FOR PRACTICE

(i) Healthcare staff may identify gaps in services in terms of preparing relatives and follow-up post-bereavement; (ii) Therapeutic relationships between staff and relatives enable ongoing support; (iii) Development of practice guidelines is a key consideration.

A qualitative evaluation of the provision of bereavement care accessed by service users living in a Health and Social Care Trust area in Northern Ireland

Within the health and social care sector in the United Kingdom, the management of death and bereavement has become increasingly challenging. This service evaluation sought to explore the bereavement care offered to individuals living in one Health and Social Care Trust catchment area of Northern Ireland. Qualitative interviews were conducted with key government and voluntary agency staff. The findings indicated that much of the bereavement provision is based on the interest and initiative of individual staff members, with few processes to assess the level of bereavement care needed and those best skilled to provide it. Recommendations are made for a bereavement care strategy that outlines a bereavement needs assessment process, identifying the scope of interventions and protocols for practice.

Bereavement care in primary care: a systematic literature review and narrative synthesis

BACKGROUND

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

AIM

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them. design systematic literature review.

METHOD

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

RESULTS

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to 'medicalise' normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

CONCLUSION

A small number of studies were identified, most of which were > 10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.

"A rewarding conclusion of the relationship": staff members' perspectives on providing bereavement follow-up

GOALS OF WORK

Staff members in palliative home care play an important role in supporting bereaved family members. The aim of this study was to explore staff members' perspectives on providing such support.

MATERIAL AND METHODS

Staff members in six units responded (n=120; response rate 58%) to a postal questionnaire with Likert-type and open-ended questions. The responses were analyzed using statistics and manifest content analysis.

MAIN RESULTS

None of the respondents stated that bereavement follow-up was "most often difficult," 23% "most often rather difficult," 52.5% "most often rather easy," and 12.5% "most often easy." Apart from a tendency for age to be linked to perceived difficulty, there were no apparent patterns. Bereavement follow-up was a positive opportunity to support the family member's coping with their bereavement and to get feedback on the palliative care provided. Critical aspects concerned the question of whose needs actually were being met at bereavement follow-up, i.e., the staff members' needs for getting feedback on the care provided versus the risk of burdening the family members' by reminding them of the deceased's dying trajectory. Aspects that negatively influenced the staff members' experiences were complex and related, e.g., to the family member's dissatisfaction with the care provided, to the staff member's perceived lack of competence, and to the staff member's relationship to the family member.

CONCLUSIONS

Bereavement follow-up was perceived as a rewarding conclusion to the relationship with the family member. The findings suggest that meaning-based coping might be an appropriate framework when understanding staff members' experiences with providing bereavement follow-up.

Case study research methods in end-of-life care: reflections on three studies

AIM

This paper is an evaluation of the use of case study methods, drawing on three research studies conducted by the authors in end-of-life care and bereavement.

BACKGROUND

Case study methods have their origins in social anthropology and draw on the principles of naturalistic inquiry. They have been used in a number of disciplines, including qualitative sociology, management science, education and organizational psychology for the understanding and evaluation of complex social systems. They are an appropriate research design for examining processes and outcomes in dynamic healthcare organizations, where it is important to obtain multiple perspectives.

METHOD

We explore issues in case study research design, recruitment and data collection drawing on three studies conducted between 2000 and 2005 in six community hospitals, five adult hospice bereavement services and eight childhood bereavement services in the United Kingdom. Quantitative and qualitative data were collected using interviews, focus groups, observations, documentary analysis, standardized measures and questionnaires.

DISCUSSION

The process of case study design is described, including building upon a clear rationale for the selection of cases, collection of data, preparation of single case reports, cross-case analysis and interpretation. In a critical discussion of recruitment, we recommend identification of a key contact person at each site to facilitate access and minimize misunderstanding, disruption to clinical services and 'gate-keeping'. Three principal methods of data collection: interviews, observation and documentary data analysis form the foundation of the rich data set necessary to explore cases in their situational contexts.

CONCLUSION

Case study methods may be empowering for participants because they value their experiences and reveal how their work contributes to teamwork within organizations. They can therefore be both affirming and challenging, as they may expose both conflicts and tensions.