Placing death and dying: Making place at the end of life

Patterns of shared meaning across personal narratives surrounding experiences with palliative care, serious illness, and the end of life

Prior observations of persistent public misconceptions and negative beliefs surrounding palliative care have led to extensive calls for public education on palliative care. Yet, the development of effective initiatives to improve public perceptions of palliative care is still hindered by a lack of research providing a deeper, contextualized understanding of the way people perceive and give meaning to palliative care. This study therefore set out to explore patterns of shared meaning across personal narratives surrounding experiences with palliative care, serious illness, and the end of life. These narratives were collected during a broad public engagement initiative on palliative care in Flanders, Belgium which included a call to share personal stories surrounding palliative care (which 72 persons did) as well as a Citizens' Forum in which 24 persons engaged in live conversations on palliative care. Reflexive thematic analysis was used to analyze the personal narratives and yielded four axes of meaning: 1) 'Sense of Support', describing feeling supported or abandoned on multiple levels with key elements of open and empathetic communication, being informed and listened to; 2) 'Being-in-Time', incorporating a renewed sense of temporality and the weight of uncertain prognosis; 3) 'Constituting a Sense of Self while Coping with Life-Threatening Illness', involving concerns surrounding role adjustments and posthumous reputation; and 4) 'Going Through the Process of Dying', unique to bereaved individuals' narratives, highlighting the importance of being informed during the dying process and honoring the wishes of the dying person. Together, these axes illuminate how both positive and stigmatized views on palliative care are shaped by broader patterns of meaning attribution, deeply ingrained in personal and social contexts. The identified narrative elements can play a crucial role in improving the content, reach, and impact of future public communication and education on palliative care, effectively enhancing public receptivity and engagement.

Home Health Care and Place of Death in Medicare Beneficiaries With and Without Dementia

BACKGROUND AND OBJECTIVES

Home health care supports patient goals for aging in place. Our objective was to determine if home health care use in the last 3 years of life reduces the risk of inpatient death without hospice.

RESEARCH DESIGN AND METHODS

We analyzed the characteristics of 2,065,300 Medicare beneficiaries who died in 2019 and conducted multinomial logistic regression analyses to evaluate the association between the use and timing of home health care, dementia diagnosis, and place of death.

RESULTS

Receiving any home health care in the last 3 years of life was associated with a lower probability of inpatient death without hospice (Pr 23.3% vs 31.5%, p < .001), and this effect was stronger when home health care began prior to versus during the last year of life (Pr 22.5% vs 24.3%, p < .001). Among all decedents, the probability of death at home with hospice compared to inpatient death with hospice was greater when any home health care was used (Pr 46.0% vs 36.5%, p < .001), and this association was strongest among beneficiaries with dementia who started home health care at least 1 year prior to death (Pr 55.6%, p < .001).

DISCUSSION AND IMPLICATIONS

Use of home health care during the last 3 years of life was associated with reduced rates of inpatient death without hospice, and increased rates of home death with hospice. Increasing affordable access to home health care can positively affect end-of-life care outcomes for older Americans and their family caregivers, especially those with dementia.

The perceptions and experiences of community nurses and patients towards shared decision-making in the home setting: An integrative review

AIM

To explore patients' and community nurses' perceptions and experiences of shared decision-making in the home.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, British Nursing Index, Psycinfo, Medline and Social Services Abstracts were searched for qualitative, quantitative and mixed methods papers published between 1 December 2001 and 31 October 2023.

REVIEW METHODS

A systematic search of electronic databases was undertaken using defined inclusion criteria. The included papers were appraised for quality using the Joanna Briggs Institute critical appraisal checklist for qualitative research. Relevant data were extracted and thematically analysed.

RESULTS

Fourteen papers comprising 13 research studies were included. Patients attached great importance to their right to be involved in decision-making and noted feeling valued as a unique individual. Communication and trust between the patient and nurse were perceived as fundamental. However, shared decision-making does not always occur in practice. Nurses described tension in managing patients' involvement in decision-making.

CONCLUSION

The findings demonstrate that although patients and community nurses appreciate participating in shared decision-making within the home, there are obstacles to achieving a collaborative process. This is especially relevant when there are fundamentally different perspectives on the decision being made. More research is needed to gain further understanding of how shared decision-making plays out in practice and to understand the tensions that patients and nurses may experience.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This paper argues that shared decision-making is more than the development of a relationship where the patient can express their views (though of course, this is important). Shared decision-making requires acknowledgement that the patient has the right to full information and should be empowered to choose between options. Nurses should not assume that shared decision-making in community nursing is easy to facilitate and should recognize the tensions that might exist when true patient choice is enabled.

IMPACT

This paper demonstrates how the idea of shared decision-making needs to be explored in the light of everyday practice so that challenges and barriers can be overcome. In particular, the tensions that arise when patients and nurses do not share the same perspective. This paper speaks to the potential of a gap surrounding shared decision-making in theory and how it plays out in practice.

REPORTING METHOD

The reporting of this review was guided by the 2020 guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Page et al., 2021).

PATIENT OR PUBLIC CONTRIBUTION

This review was carried out as part of a wider study for which service users have been consulted.

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

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

Remaking critical care: Place, body work and the materialities of care in the COVID intensive care unit

In this article, we take forward sociological ways of knowing care-in-practice, in particular work in critical care. To do so, we analyse the experiences of staff working in critical care during the first wave of the COVID-19 pandemic in the UK. This moment of exception throws into sharp relief the ways in which work and place were reconfigured during conditions of pandemic surge, and shows how critical care depends at all times on the co-constitution of place, practices and relations. Our analysis draws on sociological and anthropological work on the material culture of health care and its sensory instantiations. Pursuing this through a study of the experiences of 40 staff across four intensive care units (ICUs) in 2020, we provide an empirical and theoretical elaboration of how place, body work and care are mutually co-constitutive. We argue that the ICU does not exist independently of the constant embodied work of care and place-making which iteratively constitute critical care as a total system of relations.

Disparities in the Place of Death for Patients With Malignant Neoplasms of the Thyroid Gland

Introduction This study aims to examine the disparities in the place of death for patients due to thyroid neoplasms and understand the mortality trends. The study also aims to assess the influence of factors like age, gender, geography, and race, thus allowing for the assessment and improvement of end-of-life and palliative care. Methodology The study analyzes thyroid cancer mortality trends from 1999 to 2020 using the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database, taking into consideration locations of death, medical facilities, home and hospice care, and others. Additional categories such as race, gender, and U.S. census regions were variables chosen to segregate the deaths. Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States) and autoregressive integrated moving average (ARIMA) modeling were used for data analysis. Results The study revealed that around 50% of thyroid cancer patients in the United States passed away at home or in hospice settings, while the other 50% died in medical facilities or nursing homes. Patients aged 65-74 and 75-84 were more likely to die at home or in hospice, and males had a higher likelihood of dying in these settings compared to females. Geographically, individuals in the South and West regions were more inclined to die at home or in hospice. Additionally, racial disparities were observed, with Black or African Americans being less likely than Whites to die in home or hospice settings. Conclusions Socio-demographic factors play a major role in shaping end-of-life care, underscoring the need for tailored interventions. There is also a need for more refined early diagnostic techniques for smaller, localized tumors. Future studies should investigate the relationship between profession and income and the incidence and mortality of thyroid cancer.

"You can't die here": an exploration of the barriers to dying-in-place for structurally vulnerable populations in an urban centre in British Columbia, Canada

BACKGROUND

One measure of quality in palliative care involves ensuring people approaching the end of life are able to receive care, and ultimately die, in the places they choose. Canadian palliative care policy directives stem from this tenet of autonomy, acknowledging that most people prefer to die at home, where they feel safe and comfortable. Limited research, however, considers the lack of 'choice' people positioned as structurally vulnerable (e.g., experiencing extreme poverty, homelessness, substance-use/criminalization, etc.) have in regard to places of care and death, with the option of dying-in-place most often denied.

METHODS

Drawing from ethnographic and participatory action research data collected during two studies that took place from 2014 to 2019 in an urban centre in British Columbia, Canada, this analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place. Participants include: (1) people positioned as structurally vulnerable on a palliative trajectory; (2) their informal support persons/family caregivers (e.g., street family); (3) community service providers (e.g., housing workers, medical professionals); and (4) key informants (e.g., managers, medical directors, executive directors). Data includes observational fieldnotes, focus group and interviews transcripts. Interpretive thematic analytic techniques were employed.

RESULTS

Participants on a palliative trajectory lacked access to stable, affordable, or permanent housing, yet expressed their desire to stay 'in-place' at the end of life. Analysis reveals three main barriers impeding their 'choice' to remain in-place at the end of life: (1) Misaligned perceptions of risk and safety; (2) Challenges managing pain in the context of substance use, stigma, and discrimination; and (3) Gaps between protocols, policies, and procedures for health teams.

CONCLUSIONS

Findings demonstrate how the rhetoric of 'choice' in regard to preferred place of death is ethically problematic because experienced inequities are produced and constrained by socio-structural forces that reach beyond individuals' control. Ultimately, our findings contribute suggestions for policy, programs and practice to enhance inclusiveness in palliative care. Re-defining 'home' within palliative care, enhancing supports, education, and training for community care workers, integrating palliative approaches to care into the everyday work of non-health care providers, and acknowledging, valuing, and building upon existing relations of care can help to overcome existing barriers to delivering palliative care in various settings and increase the opportunity for all to spend their end of life in the places that they prefer.

'Thank goodness you're here'. Exploring the impact on patients, family carers and staff of enhanced 7-day specialist palliative care services: A mixed methods study

BACKGROUND

Healthcare usage patterns change for people with life limiting illness as death approaches, with increasing use of out-of-hours services. How best to provide care out of hours is unclear.

AIM

To evaluate the effectiveness and effect of enhancements to 7-day specialist palliative care services, and to explore a range of perspectives on these enhanced services.

DESIGN

An exploratory longitudinal mixed-methods convergent design. This incorporated a quasi-experimental uncontrolled pre-post study using routine data, followed by semi-structured interviews with patients, family carers and health care professionals.

SETTING/PARTICIPANTS

Data were collected within specialist palliative care services across two UK localities between 2018 and 2020. Routine data from 5601 unique individuals were analysed, with post-intervention interview data from patients (n = 19), family carers (n = 23) and health care professionals (n = 33; n = 33 time 1, n = 20 time 2).

RESULTS

The mean age of people receiving care was 73 years, predominantly white (90%) and with cancer (42%). There were trends for those in the intervention (enhanced care) period to stay in hospital 0.16 days fewer, but be hospitalised 2.67 more times. Females stayed almost 3.5 more days in the hospital, but were admitted 2.48 fewer times. People with cancer had shorter hospitalisations (4 days fewer), and had two fewer admission episodes. Themes from the qualitative data included responsiveness (of the service); reassurance; relationships; reciprocity (between patients, family carers and staff) and retention (of service staff).

CONCLUSIONS

Enhanced seven-day services provide high quality integrated palliative care, with positive experiences for patients, carers and staff.

Disparities in testicular cancer incidence, mortality, and place of death trends from 1999 to 2020: A comprehensive cohort study

BACKGROUND

Testicular cancer (TC) mortality rates have decreased over time, however it is unclear whether these improvements are consistent across all communities.

AIMS

The aim of this study was to analyze trends in TC incidence, mortality, and place of death (PoD) in the United States between 1999-2020 and identify disparities across race, ethnicity, and geographic location.

METHODS AND RESULTS

This cross-sectional study used CDC WONDER and NAACCR, to calculate age-adjusted rates of TC incidence and mortality, respectively. PoD data for individuals who died of TC were collected from CDC WONDER. Using Joinpoint analysis, longitudinal mortality trends were evaluated by age, race, ethnicity, US census region, and urbanization category. TC stage (localized vs metastatic) trends were also evaluated. Univariate and multivariate regression analysis identified demographic disparities for PoD. A total of 8,456 patients died of TC from 1999-2020. Average annual percent change (AAPC) of testicular cancer-specific mortality (TCSM) remained largely stable (AAPC, 0.4; 95% CI -0.2 to 0.9; p = 0.215). Men ages 25-29 experienced a significant increase in TCSM (AAPC, 1.3, p = 0.003), consistent with increased metastatic testicular cancer-specific incidence (TCSI) trend for this age group (AAPC, 1.6; p < 0.01). Mortality increased for Hispanic men (AAPC, 1.7, p < 0.001), with increased metastatic TCSI (AAPC, 2.5; p < 0.001). Finally, younger (<45), single, and Hispanic or Black men were more likely to die in medical facilities (all p < 0.001). The retrospective study design is a limitation.

CONCLUSION

Significant increases in metastatic TC were found for Hispanic men and men aged 25-29 potentially driving increasing testicular cancer specific mortality in these groups. Evidence of racial and ethnic differences in place of death may also highlight treatment disparities.

Palliative care practices and policies in diverse socio-cultural contexts: aims and framework of the ERC globalizing palliative care comparative ethnographic study

Background

Palliative care as a specialist professional practice of care for people with advanced illness is becoming increasingly influential worldwide. This process is affected by global health inequalities as well as cultural dimensions of approaching death and practicing care in life-limiting illness.

Objectives

The European Research Council-funded Globalizing Palliative Care (ENDofLIFE) project aims to understand how palliative care policies, discourses and practices are translated, adapted and reconstituted in diverse socio-cultural settings and how cultural dimensions of approaching death and local practices of care shape palliative care implementation.

Methods and Analysis

Using a multi-scalar and multi-sited ethnographic approach, the project uses person-centered ethnography, participant observation, semi-structured interviewing, focus group discussions and policy and discourse analysis at transnational, national and local levels. Ethnographic case-studies are conducted in Brazil, India and Indonesia.

Discussion

The globalizing palliative care project develops a novel ethnographic methodology of studying end-of-life care trajectories through long-term participant observation with individual patients and families as they manage and practice formal and informal health care in advanced illness. By analyzing how patients and families experience and navigate care over time, complemented by stakeholder interviews, the study advances critical theoretical insight into the relation between (large-scale and dynamically traveling) palliative care models, policies and discourses on the one hand and the experience and practice of palliative care in the lives of patients and informal care givers in local health care practices on the other hand. Insights are expected to benefit culturally situated palliative care policies and practices.

The fluid hospital: On the making of care environments in COVID-19

This paper explores the boundary-making practices enacted by the hospital. Taking a hospital in Sydney, Australia, as our case, we investigate how the hospital holds together as a care environment through the coordinating movements of many materials, spaces, bodies, technologies, and affects. Drawing on interviews with hospital healthcare workers involved in care, research, and management related to COVID-19, we examine the multiplying effects of these movements to trace the ways in which the hospital is (re)made in relation with pandemic assemblages. We accentuate the material affordances of care environments and how care is adapted through the reshaping of the spaces and flows of the hospital. Through this, we highlight how care providers can work with the fluidity of the hospital, including through reorganizing routines and spaces of care, engaging with communication technologies to enact care at many scales, and remaking mundane materials as medical objects in the evolving care environment.

The effectiveness of community-based palliative care programme components: a systematic review

BACKGROUND

There is evidence that community-based palliative care programmes can improve patient outcomes and caregiver experiences cost-effectively. However, little is known about which specific components within these programmes contribute to improving the outcomes.

AIM

To systematically review research that evaluates the effectiveness of community-based palliative care components.

DESIGN

A systematic mixed studies review synthesising quantitative, qualitative and mixed-methods study findings using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PROSPERO: ID # CRD42022302305.

DATA SOURCES

Four databases were searched in August 2021 (CINAHL, Web of Science, ProQuest Federated and PubMed including MEDLINE) and a close review of included article references. Inclusion criteria required articles to evaluate a single, specific component of a community-based palliative care programme either within an individual programme or across several programmes.

RESULTS

Overall, a total of 1,674 articles were identified, with 57 meeting the inclusion criteria. Of the included studies, 21 were qualitative, 25 were quantitative and 11 had mixed methods. Outcome measures consistently examined included patient/caregiver satisfaction, hospital utilisation and home deaths. The components of standardised sessions (interdisciplinary meetings about patients), volunteer engagement and early intervention contributed to the success of community-based palliative care programmes.

CONCLUSIONS

Certain components of community-based palliative care programmes are effective. Such components should be implemented and tested more in low- and middle-income countries and key and vulnerable populations such as lower-income and marginalised racial or ethnic groups. In addition, more research is needed on the cost-effectiveness of individual programme components.

Comparison of functional disabilities, place of death and end-of-life medical expenditures among centenarians and non-centenarians in China: a series of cross-sectional studies

BACKGROUND

Long-term and end-of-life (EOL) care for older adults has become a global concern due to extended longevity, which is generally accompanied by increased rates of disability. However, differences in the rates of disability in activities of daily living (ADLs), place of death and medical expenditures during the last year of life between centenarians and non-centenarians in China remain unknown. This study aims to fill this research gap to inform policy efforts for the capacity-building of long-term and EOL care for the oldest-old, especially for centenarians in China.

METHODS

Data from 20,228 decedents were derived from the 1998-2018 Chinese Longitudinal Healthy Longevity Survey. Weighted logistic and Tobit regression models were used to estimate differences in the prevalence of functional disability, rate of death in hospitals and EOL medical expenditures by age groups among oldest-old individuals.

RESULTS

Of the 20,228 samples, 12,537 oldest-old individuals were female (weighted, 58.6%, hereafter); 3,767 were octogenarians, 8,260 were nonagenarians, and 8,201 were centenarians. After controlling for other covariates, nonagenarians and centenarians experienced a greater prevalence of full dependence (average marginal differences [95% CI]: 2.7% [0%, 5.3%]; 3.8% [0.3%, 7.9%]) and partial dependence (6.9% [3.4%, 10.3%]; 15.1% [10.5%, 19.8%]) but a smaller prevalence of partial independence (-8.9% [-11.6%, -6.2%]; -16.0% [-19.1%, -12.8%]) in ADLs than octogenarians. Nonagenarians and centenarians were less likely to die in hospitals (-3.0% [-4.7%, -1.2%]; -4.3% [-6.3%, -2.2%]). Additionally, nonagenarians and centenarians reported more medical expenditures during the last year of life than octogenarians with no statistically significant differences.

CONCLUSION

The oldest-old experienced an increased prevalence of full and partial dependence in ADLs with increasing age and reported a decline in the prevalence of full independence. Compared with octogenarians, nonagenarians and centenarians were less likely to die in hospitals. Therefore, future policy efforts are warranted to optimise the service provision of long-term and EOL care by age patterns for the oldest-old population in China.

The ideal and the real: Patient and bereaved family caregiver perspectives on the significance of place of death

Home has become established as the preferred place of death within health policy and practice in the UK and internationally. However, growing awareness of the structured inequalities underpinning end-of-life care and the challenges for family members undertaking care at home raise questions about the nature of patient and public preferences and priorities regarding place of death and the feasibility of home management of the complex care needs at the end-of-life. This paper presents findings from a qualitative study of 12 patients' and 34 bereaved family caregivers' perspectives and priorities regarding place of death. Participants expressed complex and nuanced accounts in which place of death was not afforded an overarching priority. The study findings point to public pragmatism and flexibility in relation to place of death, and the misalignment of current policy with public priorities that are predominantly for comfort and companionship at the end-of-life, regardless of place.

Death, dying and disparity: an ethnography of differently priced residential care homes for older people

Recent scholarship has highlighted the experiences of, and various challenges faced by, dying persons and the workers tasked with end-of-life care. However, research has not sufficiently considered what symbolic resources – such as beliefs, rituals and vocabularies – are drawn upon by care workers when caring for dying and deceased residents in care homes, together with how this is informed by financial regimes. I address this deficit by drawing upon an extensive ethnographic study, undertaken in southern England (United Kingdom) between 2013 and 2014, at two residential care homes (one low-cost and one high-cost) for older people. Counter to analyses of death and dying that too frequently foreground the extraordinary, rather than the mundane and everyday, I examine the gaping disparities between two differently priced settings. In the low-cost home, residents experience a social and moral death. The dying and the dead are treated with disregard and indifference. In the high-cost home, caring for the living was extended beyond the biological termination of life. This was influenced not only by the marketing of ‘high-quality’ care, but also by workers and residents who, in their gestures and rituals of honouring, remembering and mourning the dead, made high-quality care possible. My analysis shows, then, how cavernous inequities unfold within the care sector and how, in turn, experiences of death and dying are deeply fragmented by the market. I conclude by arguing that researchers must both take the normative and symbolic culture of care work seriously and examine how the availability of this is directly impacted by the costing and funding of care. Doing so, I argue, allows us to work towards establishing a care sector that is equitable both for older people and care workers.

Changes in Place of Death of Older Adults during the COVID-19 Pandemic: A Retrospective Study from an Aging Country

In the COVID-19 pandemic, due to the difficulties in patients' applications to health centres, changes have occurred in the places of death of older adults. It is aimed to investigate the change in the places of death of older adults in Turkey, which is one of the countries most affected by the pandemic. Patients admitted to the geriatric outpatient clinic of a university hospital from 01.01.2013 to 29.02.2020 were included. Place and date of death were recorded as hospital or out-of-hospital death. According to results, while the median age of those who died during the pandemic was higher than before (p < 0.001) and during the pandemic, the hospital mortality ratio was higher than before. During the pandemic period, the hospital mortality ratio of older adults has increased in Turkey. This situation, which has occurred despite the increasing healthcare burden, can show the importance of the measures taken and robust health infrastructure.

Emergency medical services: the next linking asset for public health approaches to palliative care?

Emergency medical services (EMS) are a unique workforce providing 24/7 emergency care across high-income countries (HICs) and low- and middle-income countries (LMICs). Although traditionally perceived as first responders to traumatic and medical emergencies, EMS scope of practice has evolved to respond to the changing needs of communities, including a growing demand for community-based palliative care. Public health provides a useful framework to conceptualise palliative and end-of-life care in community-based settings. However, countries lack public policy frameworks recognising the role EMS can play in initiating palliative approaches in the community, facilitating goals of care at end of life and transporting patients to preferred care settings. This article aims to explore the potential role of EMS in a public health palliative care approach in a critical discussion essay format by (1) discussing the utility of EMS within a public health palliative care approach, (2) identifying the current barriers preventing public health approaches to EMS palliative care provision and (3) outlining a way forward through priorities for future research, policy, education and practice. EMS facilitate equitable access, early provision, expert care and efficacious integration of community-based palliative care. However, numerous structural, cultural and practice barriers exist, appearing ubiquitous across both HICs and LMICs. A Public Health Palliative Care approach to EMS Framework highlights the opportunity for EMS to work as a linking asset to build capacity and capability to support palliative care in place; connect patients to health and community supports; integrate alternative pathways by engaging multidisciplinary teams of care; and reduce avoidable hospital admissions by facilitating home-based deaths. This article articulates a public health approach to EMS palliative and end-of-life care provision and offers a preliminary framework to illustrate the components of a potential implementation and policy strategy.

Dying at home for people experiencing financial hardship and deprivation: How health and social care professionals recognise and reflect on patients’ circumstances

Background:

International palliative care policy often views home as the most desirable location for end-of-life care. However, people living in more deprived areas can worry about dying in poor material circumstances and report more benefits from hospital admission at the end of life. There is increasing recognition of inequities in the experience of palliative care, particularly for people living in more deprived areas. Promoting an equity agenda in palliative care means building healthcare professionals’ capacity to respond to the social determinants of health when working with patients near the end of their life.

Objectives:

The purpose of this article is to present data which reveal how some health and social care professionals view home dying for people experiencing financial hardship and deprivation.

Design:

This work was framed by social constructionist epistemology.

Methods:

Semi-structured qualitative interviews ( n = 12) were conducted with health and social care professionals who support people at the end of life. Participants were recruited from one rural and one urban health board area in Scotland, UK. Data collection occurred between February and October 2021.

Analysis:

Thematic analysis was used to analyse the interview data.

Discussion:

Our findings suggest that healthcare staff relied on physical clues in the home environment to identify if people were experiencing financial hardship, found discussions around poverty challenging and lacked awareness of how inequities intersect at the end of life. Health professionals undertook ‘placing’ work to try and make the home environment a suitable space for dying, but some barriers were seen as insurmountable. There was recognition that increased partnership working and education could improve patient experiences. We argue further research is needed to capture the perspectives of individuals with direct lived experience of end-of-life care and financial hardship.

"Dignity as a Small Candle Flame That Doesn't Go Out!": An Interpretative Phenomenological Study with Patients Living with Advanced Chronic Obstructive Pulmonary Disease

Long-term illness, such as chronic obstructive pulmonary disease (COPD), can expose people to existential suffering that threatens their dignity. This qualitative study explored the lived experiences of patients with advanced COPD in relation to dignity. An interpretative phenomenological approach based on lifeworld existentials was conducted to explore and understand the world of the lived experience. Twenty individuals with advanced COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages III and IV) were selected using a purposive sampling strategy. In-depth interviews were used to collect data, which were then analysed using Van Manen's phenomenology of practice. The existential experience of dignity was understood, in essence, as "a small candle flame that doesn't go out!". Four intertwined constituents illuminated the phenomenon: "Lived body-balancing between sick body and willingness to continue"; "Lived relations-balancing between self-control and belongingness"; "Lived Time-balancing between past, present and a limited future"; and "Lived space-balancing between safe places and non-compassionate places". This study explains how existential life phenomena are experienced during the final phases of the COPD trajectory and provides ethical awareness of how dignity is lived. More research is needed to investigate innovative approaches to manage complex care in advanced COPD, in order to assist patients in discovering their inner resources to develop and promote dignity.

Location of Death in Developed Countries: Are Hospitals a Primary Place of Death and Dying Now?

Hospitals used to be a common site of death and dying. This scoping project sought published and unpublished information on current hospital death rates in developed countries. In total, death place information was gained from 21 countries, with the hospital death rate varying considerably from 23.9% in the Netherlands to 68.3% in Japan. This major difference is discussed, as well as the problem that death place information does not appear to be routinely collected or reported on in many developed countries. Without this information, efforts to ensure high quality end-of-life (EOL) care and good deaths are hampered.

If not home, where? Implementing an innovative model of care as an alternative place of care & death for patients living in an area of high socio-economic deprivation. Short-report on opening a long-term palliative care unit

BACKGROUND

Healthcare professionals and policy makers often view home as the most appropriate place of care and death for patients. However, this makes assumptions about what home is like and does not account for high levels of complexity experienced by patients from areas of high socioeconomic deprivation. Alternative models of care should be explored to provide equitable care for this patient group.

AIMS

To describe the development of a new innovative model of care, a long-term palliative care unit.

DESIGN

Description of the model, with secondary analysis of retrospective routinely gathered data.

SETTING

Hartlepool in North-East England, includes some of the most socio-economically deprived areas in England, with associated high-levels of multimorbidity. In 2014, the eight-bedded hospice, opened an additional 10-bedded long-term unit.

RESULTS

Within 7 years, 199 patients were admitted to the long-term unit. With 98% remained there until death. All patients were offered a full holistic assessment and advance care planning, with 24/7 access to specialist palliative care support. None were transferred to hospital. In general, patients from socio-economically deprived areas are less likely to access hospice care, however, 27% of all admissions to the long-term unit were from areas in the 10% most deprived in England (with 41% admitted from areas in the poorest quintile).

CONCLUSION

We suggest that this model has been a valuable asset in providing an alternative place to home, enabling patients to receive high-quality care towards end of life. Further research is needed to hear directly from patients about their experiences.

The challenges homeless people face when accessing end-of-life care: what district nurses need to know

People experiencing homelessness have poorer physical and mental health compared with the rest of the population. Mortality rates are significantly higher, yet there is a dearth in suitable places for the delivery of palliative and end-of-life (EOL) care. Homeless people are being failed by the current healthcare system. The stigma associated with being homeless negatively impacts these marginalised people, affecting care given from healthcare professionals (HCP). Services are often inflexible and have little tolerance for substance misuse. District Nurses (DN) are often experienced EOL care practitioners and well-placed to give person-centred care with a focus on collaborative decision-making. However, many homeless people die without input from DNs or specialist palliative support. It is important to understand why this is happening to address what can be done to help.

Multidisciplinary team meetings in palliative care: an ethnographic study

OBJECTIVES

Multidisciplinary team meetings are a regular feature in the provision of palliative care, involving a range of professionals. Yet, their purpose and best format are not necessarily well understood or documented. This article describes how hospital and community-based palliative care multidisciplinary team meetings operate to elucidate some of their main values and offer an opportunity to share examples of good practice.

METHODS

Ethnographic observations of over 70 multidisciplinary team meetings between May 2018 and January 2020 in hospital and community palliative care settings in intercity London. These observations were part of a larger study examining palliative care processes. Fieldnotes were thematically analysed.

RESULTS

This article analyses how the meetings operated in terms of their setup, participants and general order of business. Meetings provided a space where patients, families and professionals could be cared for through regular discussions of service provision.

CONCLUSIONS

Meetings served a variety of functions. Alongside discussing the more technical, clinical and practical aspects that are formally recognised aspects of the meetings, an additional core value was enabling affectual aspects of dealing with people who are dying to be acknowledged and processed collectively. Insight into how the meetings are structured and operate offer input for future practice.

Healthcare professionals' perspectives of patient and family preferences of patient place of death: a qualitative study

BACKGROUND

Home death is one of the key performance indicators of the quality of palliative care service delivery. Such a measure has direct implications on everyone involved at the end of life of a dying patient, including a patient's carers and healthcare professionals. There are no studies that focus on the views of the team of integrated inpatient and community palliative care service staff on the issue of preference of place of death of their patients. This study addresses that gap.

METHODS

Thirty-eight participants from five disciplines in two South Australian (SA) public hospitals working within a multidisciplinary inpatient and community integrated specialist palliative care service, participated in audio-recorded focus groups and one-on-one interviews. Data were transcribed and thematically analysed.

RESULTS

Two major and five minor themes were identified. The first theme focused on the role of healthcare professionals in decisions regarding place of death, and consisted of two minor themes, that healthcare professionals act to: a) mediate conversations between patient and carer; and b) adjust expectations and facilitate informed choice. The second theme, healthcare professionals' perspectives on the preference of place of death, comprised three minor themes, identifying: a) the characteristics of the preferred place of death; b) home as a romanticised place of death; and c) the implications of idealising home death.

CONCLUSION

Healthcare professionals support and actively influence the decision-making of patients and family regarding preference of place of death whilst acting to protect the relationship between the patient and their family/carer. Further, according to healthcare professionals, home is neither always the most preferred nor the ideal place for death. Therefore, branding home death as the ideal and hospital death as a failure sets up families/carers to feel guilty if a home death is not achieved and undermines the need for and appropriateness of death in institutionalised settings.