Research into care at the end of life

The role of geriatricians in hospital palliative care units for elderly patients affected by end stage diseases

OBJECTIVE

To show the importance of geriatricians in the assessment and treatment of patients with terminal illnesses requiring palliative care.

METHODS

This was a retrospective epidemiological study, in which the authors used data relating to 229 patients with terminal stage cancer/advanced chronic diseases, which were evaluated by a palliative care team and collected from January to December 2018.

RESULTS

The average age of the sample was 72 years. The sample was divided into two groups, called 'advanced cancer' (N=161, 70.3%) and 'advanced chronic diseases' (N=68, 29.6%). The authors found that patients with advanced chronic diseases had the highest age, highest number of comorbidities and higher indicators of complex care. The authors also showed that, in advanced chronic diseases, the factors that are associated with increased hospital death are: bedridden (OR=3,778; 95% CI=1,371-10,409), dysphagia (OR=2,038; 95% CI=1,005-4,133) and a higher number of diseases (OR=1,446; 95% CI=1,179-1,774).

DISCUSSION

Given these findings, there is a high prevalence of elderly hospitalised patients with advanced chronic end-stage disease, a classic geriatric condition, who need access to palliative care services.

CONCLUSION

The authors believe that an increase in geriatricians dedicated to palliative care services is needed to ensure that these patients have equal access to continuity of care services and optimal treatment.

Family functioning and negative emotions in older adults: the mediating role of self-integrity and the moderating role of self-stereotyping

OBJECTIVES

The objective of this study was to examine a possible mediator role of self-integrity and a moderator role of self-stereotyping in the relationship between family functioning and negative emotions in older adults.

METHOD

A total of 1186 older adults participated in the current study. They completed measures related to family functioning, self-integrity, self-stereotyping, depression, anxiety, and loneliness.

RESULTS

Older adults with family dysfunction experienced more negative emotions than those with healthy family functioning, a finding which could be explained by the levels of self-integrity. Older adults with high levels of self-stereotyping, unhealthy family functioning, and low self-integrity were significantly more likely to be depressed and anxious than those with low levels of self-stereotyping.

CONCLUSION

Family functioning negatively predicted negative emotions, self-integrity mediated the link between family functioning and negative emotions, and self-stereotyping moderated the direct and indirect effects of family functioning on depression and anxiety via self-integrity.

Overcoming barriers to recruitment in care of the dying research in hospitals

CONTEXT

Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging.

OBJECTIVES

We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives.

METHODS

A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, "Is this patient so unwell that you feel they could die on this admission?" to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died.

RESULTS

In total, 6642 patients were screened. The ward staff answered "yes" to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate.

CONCLUSION

We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

Patient, caregiver, health professional and researcher views and experiences of participating in research at the end of life: a critical interpretive synthesis of the literature

Background

The development of the evidence-base informing end of life (EoL) care is hampered by the assumption that patients at the EoL are too vulnerable to participate in research. This study aims to systematically and critically review the evidence regarding the experiences and views of patients, caregivers, professionals and researchers about participation in EoL care research, and to identify best practices in research participation.

Methods

We searched seven electronic databases, and hand searched three journals and the bibliographies of relevant papers. Inclusion criteria were original research papers on involvement in EoL care research or its impact on participants. Critical interpretive synthesis was used to integrate the whole body of empirical evidence on this topic and generate theoretical categories from the evidence.

Results

Of a total of 239 identified studies, 20 studies met the inclusion criteria, from: the US (11), the UK (6) and Australia (3). Most focused on patients with cancer (12) and were conducted in hospices (9) or hospitals (7). Studies enquired about issues related to: EoL care research in general (5), specific research methods (13), and trial research (2). The studies evaluating willingness to participate in EoL care research showed positive outcomes across the different parties involved in research. Factors influencing willingness were mainly physical and cognitive impairment. Participating in research was a positive experience for most patients and carers but a minority experienced distress. This was related to: characteristics of the participants; the type of research; or the way it was conducted. Participatory study designs were found particularly suitable for enabling the inclusion of a wide range of participants.

Conclusion

The evidence explored within this study demonstrates that the ethical concerns regarding patient participation in EoL care research are often unjustified. However, research studies in EoL care require careful design and execution that incorporates sensitivity to participants’ needs and concerns to enable their participation. An innovative conceptual model for research participation relevant for potentially vulnerable people was developed.

Culture is a priority for research in end-of-life care in Europe: a research agenda

CONTEXT

Culture has a profound influence on our understanding of what is appropriate care for patients at the end of life (EoL), but the evidence base is largely nonexistent.

OBJECTIVES

An international workshop was organized to compile a research agenda for cultural issues in EoL research, and assess challenges and implications of the integration of the culture concept in different contexts.

METHODS

Participant experts were identified from the expert network established through an Internet-based call for expertise on culture and EoL care and from meetings. The workshop comprised presentations of research priorities from country and disciplinary perspectives, and group discussions. Analysis used all data gathered in the workshop and applied standard qualitative techniques.

RESULTS

Thirty experts participated in the workshop and identified the following priorities for cross-cultural research: 1) clarifying the concepts of culture and cultural competence; 2) defining EoL in a context of social and cultural diversity, with a focus on concepts of EoL care and bioethics, experiences of receiving and giving EoL care, and care practices in different settings; and 3) developing appropriate methodologies and outcome measurements that address diversity.

CONCLUSION

This first pan-European meeting compiled a research agenda, identifying key areas for future research focusing on culture, diversity, and their operationalization. This requires international and multidisciplinary collaboration, which is necessary in the current efforts to synthesize best practices in EoL care.

Palliative care research in Latin America and the Caribbean: from the beginning to the Declaration of Venice and beyond

BACKGROUND

Research in palliative care has increased significantly in the last decade, while the vast majority of the global disease burden occurs in developing countries.

AIMS

To explore the palliative care research activity in Latin America and the Caribbean (LAC) and its visibility in the international palliative care literature, with a special focus on research studies.

METHODS

A bibliometric analysis was conducted in MEDLINE(®), Embase(®), PsycINFO(®), and CINAHL(®). Inclusion criteria were: (1) articles published in peer-reviewed scientific journals; (2) main subject was palliative care; (3) research study; (4) the first author or coauthors was based in LAC; and/or (5) the data collected derived from LAC.

RESULTS

One hundred six articles from 10 countries were identified in the literature research. The first publication dates from 1989 and was a qualitative study in Brazil. This study shows a modest contribution of publications from LAC. However, the volume of publications within the region is distributed unequally, reflecting the heterogeneity of the region: Brazil published more than half of the articles, while 35 countries have no publications. Most of the studies were quantitative research, predominantly cross-sectional studies. Qualitative studies often used interviews. Health care service was the most researched issue. Seventy percent of studies were carried out in institutions.

CONCLUSIONS

Palliative care research should have a place in LAC. The development of a regional research agenda tailored to the needs and features of the region considering the health care structure and local resources available is indispensable.

Culture and end of life care: a scoping exercise in seven European countries

AIM

Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries.

METHODS

We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes.

RESULTS

A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities.

CONCLUSION

This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Prescription patterns of analgesics in the last 3 months of life: a retrospective analysis of 10202 lung cancer patients

BACKGROUND

To describe the prescription patterns of analgesics during the last 3 months of life in lung cancer and to determine the associated factors.

METHODS

Data on lung cancer patients (N=10,202) who died during 2000-2008 were extracted from the General Practice Research Database (GPRD). This database records prescriptions of patients received from UK general practices (GP), but not those from non-GP routes. Prescription prevalences were estimated. The associated factors were investigated using log-binomial regression.

RESULTS

The overall prescription prevalences were 50.4% (95% confidence interval (CI): 49.4-51.4%) for level 1 (e.g., paracetamol), 34.1% (95% CI: 33.2-35.0%) for level 2 (weak opioids), and 55.5 % (95% CI: 54.5-56.4%) for level 3 analgesics (strong opioids). Prescription prevalence of analgesics of all levels showed an increasing trend over the period 2000-2008 (annual increases range: 1.1-1.5%) but a decreasing trend with age (average decrease per group range: -5.8 to -1.8%). Patients in the older age groups were less likely to be prescribed level 3 analgesics than those in the younger age groups (PR('90+' vs '<50')=0.55 (95% CI: 0.45-0.67); PR('80-89' vs '<50')=0.73 (95% CI: 0.66-0.79); PR('70-79' vs '<50')=0.84 (95% CI: 0.77-0.90)).

CONCLUSION

Analgesics have been increasingly prescribed in lung cancer. However, analgesics, especially at level 3, were relatively under-prescribed to people older than 70 years, warranting further investigation.

Disparities in the contribution of low- and middle-income countries to palliative care research

CONTEXT

Important aspects of the palliative care needs of patients from low- and middle-income countries (LMIC) are largely unexplored. About 44 million of the 56 million annual deaths worldwide occur in developing countries, and it is estimated that more than 33 million of those concerned would benefit from palliative care. In this context, the understanding of specific social and cultural needs is fundamental to the development of appropriate health policy and clinical practice concerning palliative and end-of-life care.

OBJECTIVES

This study aims to answer the question: what are the contributions, in terms of generation of knowledge, of LMIC to the published palliative care literature?

METHODS

A bibliometric analysis was conducted in Medline and EMBASE (to June 2008). Articles were included when either the first author (institutional affiliation or contact address) or the data collection was derived from LMIC, as defined by criteria of the World Bank. Excluded were articles done in migrant and non-palliative care populations.

RESULTS

The literature search resulted in 845 references. In total, 245 articles coming from LMIC were identified, being published by 34 LMIC (27.3% of LMIC). The first publications appeared in 1982. The study shows a rather modest contribution of publications from LMIC. However, the volume of publications within LMIC is distributed unequally: upper-middle-income countries published almost half of the articles (46.9%), whereas only 11% of the publications came from low-income countries. In contrast, 104 LMIC (72.7% of LMIC) do not have any registered publications. Surprisingly, 25% of the articles with data from LMIC have been done and published by high-income countries. Reasons for the underrepresentation, as well a possible correction of this imbalance, are discussed.

CONCLUSION

Palliative care research should be a priority in LMIC, where many patients could benefit tremendously from it, and publication of findings in these countries should be encouraged.

Key challenges and ways forward in researching the "good death": qualitative in-depth interview and focus group study

OBJECTIVE

To understand key challenges in researching end of life issues and identify ways of overcoming these.

DESIGN

Qualitative study involving in-depth interviews with researchers and focus groups with people affected by cancer.

PARTICIPANTS

An international sample of 32 researchers; seven patients with experience of cancer; and four carers in south east Scotland.

RESULTS

Researchers highlighted the difficulty of defining the end of life, overprotective gatekeeping by ethics committees and clinical staff, the need to factor in high attrition rates associated with deterioration or death, and managing the emotions of participants and research staff. People affected by cancer and researchers suggested that many people nearing the end of life do want to be offered the chance to participate in research, provided it is conducted sensitively. Although such research can be demanding, most researchers believed it to be no more problematic than many other areas of research and that the challenges identified can be overcome.

CONCLUSIONS

The continuing taboos around death and dying act as barriers to the commissioning and conduct of end of life research. Some people facing death, however, may want to participate in research and should be allowed to do so. Ethics committees and clinical staff must balance understandable concern about non-maleficence with the right of people with advanced illness to participate in research. Despite the inherent difficulties, end of life research can be conducted with ethical and methodological rigour. Adequate psychological support must be provided for participants, researchers, and transcribers.

Hospice partnerships with academic entities: philosophical and historical background and assessment of future needs

There is consensus that more research is needed to help improve care at the end of life. Despite the fact that hospices take care of more and more dying persons every year, hospice organizations have not been highly involved in research. The National Hospice Work Group is comprised of hospice organizations that have made promotion of research a high priority. Structured interviews were conducted with members of the National Hospice Work Group to investigate how they think about the role of academic partners in their organizational missions, what their histories of involvement with academic partners are, and what they see as their most important academic needs for continuing to advance the research agenda. Members of the National Hospice Work Group see strategic partnerships with academic entities as essential to the goal of advancing research in end-of-life care.