The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

Desire to Die: How Does the Patients' Chorus Sound?

Patients receiving palliative care often express a desire to die. Forms and backgrounds of these expressions can be diverse. To contribute to a better understanding of this phenomenon, we analyzed patients' desire to die expressions reported by palliative care providers participating in 11 communication trainings on desire to die. The 102 participants were asked to reproduce related patients' statements from their everyday practice. The 165 reported statements could be assigned to the four topics: "Putting an end to life by …," "Social death," "Death images," as well as "Specific and unspecific references to life, death and dying." Across these topics, phrasing differs particularly regarding sentence type (interrogative, declarative, propositional, exclamatory), explicitness and (the way of) referencing others (e.g. attribution of power). The compilation of statements reflects a chorus of expressions, which the palliative care providers might hear throughout their professional career as well as during a patient's process(ing) of disease.

Use of a "baby bottle" to allow a "better-than-nothing" death in older adults infected by COVID-19 in Quebec retirement homes - A case study

The COVID-19 pandemic has brought to the forefront profound questions surrounding dying and the concept of a "good death". This qualitative case study, conducted in a health center in Quebec, Canada, severely affected by outbreaks during the pandemic's first wave, explores end-of-life care for older adults in retirement homes. Through thirty interviews with healthcare practitioners, researchers, and managers, we investigate the critical role of a pharmacological device referred to as the "baby bottle" in providing end-of-life care to older adults infected with COVID-19 in their homes. Drawing upon the boundary object framework, we examine the ambiguities surrounding the use of this device and explores its agency. In this unprecedented context, we argue that the device facilitated a form of death that could be described as "better than nothing", embodying practitioners' efforts to provide some dignity to the dying person, by minimally controlling the distress and ensuring a connection between the dying person and the care team. Additionally, it served as a means of coping with the pandemic's intolerable aspects, such as the exclusion of frail older adults for the supposed common good. This study raises questions about the legitimacy and normalization of such compensatory measure within under-resourced healthcare systems for older people experiencing a loss of autonomy.

Maneuvering between cultures: The reception of hospice care in the Chinese medical community

The expansion of hospice care worldwide has been received differently by medical communities in different societies. Nonetheless, existing efforts to explain how culture affects the reception of hospice care are inadequate. On the basis of fieldwork conducted in Chinese medical institutions and care facilities between 2017 and 2022, this paper draws on a theoretical framework that distinguishes between declarative culture and nondeclarative culture at the personal level to explain the discrepancies between healthcare professionals' beliefs regarding the value of hospice care and their daily healthcare practice. Moreover, this paper uses the concept of cultural scaffolding to demonstrate that the culture of hospice care and the culture of medical institutions are not separate, independent entities but rather evolve together to produce new and local forms of hospice care in the Chinese context. This analysis helps clarify the obstacles and opportunities associated with hospice care in China and contributes to existing research on the reception of hospice care worldwide.

SATISFICING DEATH: Ageing and end-of-life preparation among transgender older Americans

A good death-a normative ideology of living and dying well that may allow an individual to gain awareness, acceptance, and preparation for death-has captured the attention of researchers, clinicians, and policymakers in recent years. Prior sociological research has uncovered nuanced perspectives of a good death, yet there has been minimal exploration into how marginalised communities reconstruct their own ideals of a good death in response to structural and institutional inequities. Utilising data from 47 in-depth interviews, I examine how transgender older adults perceive and plan for ageing and end-of-life experiences through advance care planning. My analysis reveals transgender older adults' reevaluated notions of a normatively desirable good death for themselves due to existing inequities. Consequently, they actively reconstruct a personalised ideology of death that is adequate enough to meet their end-of-life needs. I further offer the conceptualisation of SATISFICING DEATH, as a process of individuals from marginalised communities reevaluating and reconstructing their own ideologies of a good death that is adequate enough while using resourceful strategies to improve existing social conditions for themselves. These findings highlight the critical need to provide affirming end-of-life care, support, and resources to transgender communities.

Resisting the (re-)medicalisation of dying and grief in the post-digital age: Natural language processing and qualitative analysis of data from internet support forums

In the mid-twentieth century, the social movement of death revivalism sought to resist the medicalisation of dying and grief through promotion of the dying person retaining autonomy, and societal openness toward death and bereavement. Despite this advocacy, present-day dying in high income countries is largely institutionalised, with value placed on control over the body and emotions. These phenomena are at odds with the ambitions of death revivalism, and demonstrate the re-medicalisation of dying and grief. Furthermore, contemporary society is continually advancing into the post-digital age, reflected in digital technologies being a tacit part of human existence. Within this framework, this study aims to investigate how people living with life-limiting illness and their loved ones experience, negotiate, and resist medicalisation of dying and grief through online internet forums. We collected posts through web-scraping and utilised Natural Language Processing techniques to select 7048 forum posts from 2003 to 2020, and initially categorise data, before utilising Inductive Thematic Analysis, which generated two major themes. The theme of 'Comfort' describes online forums facilitating psychosocial support which was often used to compensate for systemic deficiencies, especially during the Covid-19 pandemic. Common sources of comfort included animal companions and spirituality, in stark contrast with the medicalised model. The theme of 'Capability' describes online forums acting as solutions for people facing disempowering care systems, including providing information on legal rights and benefits which may not be otherwise easily available, and facilitating collective advocacy. Our findings indicate that community-led online forums can play an effective and sustainable role in democratising care and retaining agency when facing life-limiting illness and grief. Future palliative and bereavement care research must focus on how online forums can be integrated into existing systems, made transparent and accessible, be adequately funded and structured, and be optimised, including compensating for service disruption encountered during future pandemics.

Patients', relatives' and nurses' experiences of palliative care on an advanced care ward in a nursing home setting in Norway

PATIENT OR PUBLIC CONTRIBUTION

Patients, relatives and nurses were involved in this study.

AIM

The aim was to explore patients', relatives' and nurses' experiences of palliative care on an advanced care ward in a nursing home setting after implementation of the Coordination Reform in Norway.

DESIGN

Secondary analysis of qualitative interviews.

METHODS

Data from interviews with 19 participants in a nursing home setting: severely ill older patients in palliative care, relatives and nurses. Data triangulation influenced by Miles and Huberman was used.

RESULTS

The overall theme was "Being in an unfamiliar and uncaring culture leaves end-of-life patients in desperate need of holistic, person-centred and co-creative care". The main themes were: "Desire for engaging palliative care in a hopeless and lonely situation", "Patients seeking understanding of end-of-life care in an unfamiliar setting" and "Absence of sufficient palliative care and competence creates insecurity". The patients and relatives included in this study experienced an uncaring culture, limited resources and a lack of palliative care competence, which is in direct contrast to that which is delineated in directives, guidelines and recommendations. Our findings reveal the need for policymakers to be more aware of the challenges that may arise when healthcare reforms are implemented. Future research on palliative care should include patients', relatives' and nurses' perspectives.

Combining realist evaluation and transformative evaluation to advance research in palliative care: The case of end of life companionship

BACKGROUND

Palliative care requires innovative methods to understand what works, for whom, in what circumstances and why. Realist evaluation has become one prominent approach due to its preoccupation with building, and testing, causal theories to explain the influence of contextual factors on outcomes. Undertaking realist evaluation is not without challenges and may amplify issues of underrepresentation, disempower those working in palliative care, and produce results with poor ecological validity. Complementary approaches are needed which mitigate these challenges, whilst producing credible findings that advances knowledge.

PURPOSE

In this article it is outlined how realist evaluation provides a toolkit to advance research to explain, and empirically test, the complex contours of palliative care. Moreover, it is proposed that transformative evaluation can provide a catalyst to engage and empower those within palliative care, create the opportunity for care transformation, and produce more informed and authentic theories.

DISCUSSION

Contemporary issues in palliative care pertain to the complexity of palliative care, the insufficiency of experimental designs alone, and the challenges of achieving inclusive research participation. In this article it is argued that theory led, participatory, opportunistic and naturalistic approaches can provide an antidote to the issues in the literature. The combination also mitigates many methodological critiques of the individual approaches, by increasing the transformative potential of realist evaluation, and explanatory potential of transformative evaluation.

Policy Narratives on Palliative Care in Sweden 1974-2018

In Sweden, efforts to govern end-of-life care through policies have been ongoing since the 1970s. The aim of this study is to analyse how policy narratives on palliative care in Sweden have been formulated and have changed over time since the 1970s up to 2018. We have analysed 65 different policy-documents. After having analysed the empirical material, three policy episodes were identified. In Episode 1, focus was on the need for norms, standards and a psychological end-of-life care with the main goal of solving the alleged deficiencies within end-of-life care in hospital settings. Episode 2 was characterised by an emphasis on prioritising end-of-life care and dying at home, and on the fact that the hospice care philosophy should serve as inspiration. In Episode 3, the need for a palliative care philosophy that transcended all palliative care and the importance of systematic follow-ups and indicators was endorsed. Furthermore, human value and freedom of choice were emphasised. In conclusion, the increase of policy-documents produced by the welfare-state illustrate that death and dying have become matters of public concern and responsibility. Furthermore, significant shifts in policy narratives display how notions of good palliative care change, which in turn may affect both the practice and the content of care at the end of life.

"To Be or Not to Be"-Cardiopulmonary Resuscitation for Hospitalized People Who Have a Low Probability of Benefit: Qualitative Analysis of Semi-structured Interviews

Purpose

Our aim was to understand the decision making of patients in hospital who wanted cardiopulmonary resuscitation despite low probability of benefit.

Methods

We included patients admitted to general medical wards who had a low chance of surviving in-hospital cardiopulmonary resuscitation (CPR) and had an order in the chart to administer CPR. We developed an interview guide to explore participants' decision-making process, sources of information, and emotions associated with this decision.

Results

We developed 3 themes from the data. 1) "Life is worth living . . . for now": Participants describe their enjoyment of life and desire to carry on in their current state. 2) "Making sense of CPR outcomes": Participants saw CPR outcomes as binary, either they live, or they die; deciding not to receive CPR means choosing death. Participants were optimistic they would survive CPR and cited personal experience and TV as information sources. 3) "Decision process": Participants did not engage in shared decision making. Instead, they were asked a binary yes/no question with no reflection on their values or discussion about harms or benefits.

Limitations

The probability of successful CPR in our sample is unknown. Findings may be different in a population who is imminently dying but still requesting CPR.

Conclusions

Participants chose CPR because they perceived life as worth living and CPR as a chance worth taking. Participants did not want to be left in a severely debilitated state but did not have accurate information about this risk.

Implications

Decision making about CPR in-hospital can be improved if it is grounded in accurate risk understanding and the patient's values and wishes.

Facilitating equitable access to hospice care in socially deprived areas: A mixed methods multiple case study

BACKGROUND

There is uncertainty about the factors influencing inequities in access to palliative care in socially deprived areas, including the role of service models and professional perceptions.

AIM

To explore the relationship between social deprivation and access to hospice care, including factors influencing access and professional experiences of providing care.

DESIGN

A mixed-methods multiple case study approach was used. Hospice referrals data were analysed using generalised linear mixed models and other regression analyses. Qualitative interviews with healthcare professionals were analysed using thematic analysis. Findings from different areas (cases) were compared in a cross-case analysis.

SETTING

The study took place in North West England, using data from three hospices (8699 hospice patients) and interviews with 42 healthcare professionals.

RESULTS

Social deprivation was not statistically significantly, or consistently, associated with hospice referrals in the three cases (Case 1, Incidence Rate Ratio 1.04, p = 0.75; Case 2, Incidence Rate Ratio 1.09, p = 0.15, Case 3, Incidence Rate Ratio 0.88, p = 0.35). Hospice data and interviews suggest the model of hospice care, including working relationship with hospitals, and the local nature of social deprivation influenced access. Circumstances associated with social deprivation can conflict with professional expectations within palliative care.

CONCLUSION

Hospice care in the UK can be organised in ways that facilitate referrals of patients from socially deprived areas, although uncertainty about what constitutes need limits conclusions about equity. Grounding professional narratives around expectations, responsibility, and choice in frameworks that recognise the sociostructural influences on end-of-life circumstances may help to foster more equitable palliative care.