Conceptualization of a good end-of-life experience with dementia in Japan: a qualitative study

Good Death and Quality of End-of-Life Care in Patients with Coexisting Cancer and Dementia: Perspective of Bereaved Families

Background

Patients with coexisting cancer and dementia often have complex health care needs and face challenges in achieving a good death.

Objectives

To evaluate good death achievement and end-of-life (EOL) care in patients with coexisting cancer and dementia from the perspective of bereaved families.

Design

Cross-sectional nationwide postal survey.

Setting/Subjects

Bereaved families of patients with cancer who died in hospice and palliative care units across Japan.

Measurements

Bereaved families completed an anonymous, self-reported questionnaire. Their perspective on achieving a good death was assessed using the Good Death Inventory (GDI) (total score: 18-126). The Revised Care Evaluation Scale-short version (CES2) was used to assess EOL care (total score: 10-60). We examined the Brief Grief Questionnaire (BGQ) (total score: 0-10) and Patient Health Questionnaire 9 (PHQ9) (total score: 0-27).

Results

Data from 670 participants were analyzed, including 83 (12.4%) bereaved families of patients with coexisting cancer and dementia. No statistical differences were observed in the total GDI score for 18 items (dementia comorbidity vs. nondementia comorbidity groups, mean ± standard deviation, respectively, 78.4 ± 17.7 vs. 80.0 ± 15.5, adjusted [adj] P = 0.186), CES2 score (49.70 ± 9.22 vs. 48.82 ± 8.40, adj P = 0.316), BGQ score (3.40 ± 2.41 vs. 4.36 ± 2.28, adj P = 0.060), and PHQ9 score (4.67 ± 4.71 vs. 5.50 ± 5.37, adj P = 0.788).

Conclusions

GDI, CES2, BGQ, and PHQ9 scores did not differ significantly between groups, regardless of the presence of dementia in hospice and palliative care units. Patients with coexisting cancer and dementia can achieve a good death by high-quality EOL care.

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study

BACKGROUND

Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life.

AIM

To develop a multidimensional international palliative care goals model in dementia for use in practice.

DESIGN

International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified.

SETTING/PARTICIPANTS

Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study.

RESULTS

Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves.

CONCLUSION

A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Encouraging death communication in a death-avoidant society: analysis of interviews with death café organizers

BACKGROUND

Post-war Japanese tend to avoid discussion of death, resulting in a lack of death communication within clinical settings. However, with the aging of society, the significance of conversations and decisions related to end-of-life issues has grown. In 2007, the government established guidelines for decision-making in end-of-life care. Nonetheless, death communication remains a challenge for healthcare professionals in clinical settings. In contrast, death cafés have spontaneously emerged within communities as informal gatherings to openly discuss and explore death. Learning from death café organizers may help healthcare professionals encourage death communication in a death-avoidant society. Therefore, a qualitative study was conducted to describe death cafés by examining the underlying motivation and practices through interviews with death café organizers.

METHODS

Individual in-depth interviews were conducted with death café organizers. Two key aspects were explored: 1) the underlying motivations of organizers; and 2) the practices and challenges encountered in running death cafés. The interviews were transcribed verbatim and analyzed using a qualitative descriptive approach. Thematic analysis was used.

RESULTS

The study identified two themes representing the underlying motivation of death café organizers: individually-oriented and community-oriented. These themes exhibited contrasting orientations and were collectively termed "individual-community orientation". Regarding the practice of death cafés, the focus was on the "attitude towards having attendees with and without grief in the same session." Participants' attitudes towards this aspect fell into two categories with opposing orientations: "purification" and "inclusion." The "purification-inclusion orientation" was more prevalent among organizers who initiated death cafés due to their personal experiences. A matrix was created to categorize death cafés based on their underlying motivations (individual vs. community-oriented) and practices (purification vs. inclusion). This classification resulted in quadrant 1 (community-oriented, inclusive) and quadrant 3 (individually-oriented, purification). Notably, death cafés in quadrant 1 were often held in temples.

CONCLUSIONS

Japanese death cafés can be classified into two categories: individually and purification-oriented and community and inclusive-oriented categories. Healthcare professionals can learn valuable insights from death café organizers, particularly in promoting death communication. Specifically, temple death cafés, with their inclusive practices and orientation towards community, can be particularly beneficial in fostering inclusivity and community engagement.

Cross-cultural conceptualization of a good end of life with dementia: a qualitative study

Background

Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models.

Methods

We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies.

Results

Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes.

Conclusions

The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model.

Trial registration

The Graduate School and Faculty of Medicine Kyoto University (R1924–1).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00982-9.

An exploration of the views of staff on cultural aspects of end-of-life care in Japanese long-term care facilities: a qualitative study

Long-term care facilities are increasingly important places for palliative and end-of-life care provision in Japan. While the importance of culture has been noted for palliative and end-of-life care, an exploration of its influence on care provision in long-term care settings has received little direct attention in Japan. Exploring staff views and beliefs in palliative and end-of-life care in these settings can potentially enhance our understanding of culturally oriented care and facilitate the development of tailored and more effective support practices. This study aimed to explore the cultural views and beliefs regarding palliative and end-of-life care among the staff in Japanese long-term care facilities. A qualitative exploratory study was conducted using focus groups with facility staff (N = 71) and semi-structured interviews with facility managers (N = 10) in the Kanto region of Japan. Thematic analysis was conducted according to Braun and Clarke's approach. The findings are presented in five key themes: ‘Changes in society's and family's end-of-life perspectives’, ‘Values and beliefs regarding death and dying’, ‘Anxiety and regret’, ‘Tensions in doing the right thing’ and ‘Ways of alleviating pressure’. The findings indicate that the provision of palliative and end-of-life care is underpinned by cultural nuances that influence care providers' approach and delivery. Recognising and understanding the cultural beliefs of staff around death, dying and end-of-life care are important in meeting the needs of residents. Palliative care education for staff in these settings should include cultural considerations that reflect changing societal views on death and dying.

Long-term care nurses' perceptions of a good death for people with dementia: A qualitative descriptive study

INTRODUCTION

The number of people with dementia (PwD) dying in long-term care (LTC) settings is expected to increase. However, effective care strategies to promote a good death for PwD remain unclear. This study aimed to explore nurses' perceptions of a good death for PwD in LTC settings for older adults.

METHODS

Interviews were conducted with 19 nurses providing end-of-life care in LTC settings for older adults in Japan. The transcribed texts were analysed using inductive content analysis.

RESULTS

We identified two themes: (1) ambiguity and (2) preparedness. Participants perceived that there was ambiguity regarding a good death for PwD and emphasised the need for preparedness of those around PwD for a good death. Five categories represented preparedness: (a) reaffirming the original personality before dementia; (b) respecting that PwD change; (c) interpreting and fulfilling obscure desires, feelings, and sensations; (d) providing care consistent with an agreed-upon natural death process; and (e) maintaining relationships.

CONCLUSION

Long-term care nurses should encourage families and multidisciplinary team members, including the nurses themselves, to prepare for a good death of the PwD. Future research should focus on healthcare professionals' perspectives on advance care planning in the early stages of dementia, as well as the perceptions of PwD, their family members and other healthcare professionals regarding the natural death process.

Earlier initiation of palliative care in the disease trajectory of people living with dementia: a scoping review protocol

INTRODUCTION

While the need for palliative care for people living with dementia has widely been recognised, they continue to be a disadvantaged group when it comes to timely initiation, and controversies remain regarding appropriate timing, or what elements constitute high quality palliative care early in the disease trajectory. To date, no literature review has summarised this debate or offered insights. The aim of this scoping review is to provide a general overview of research regarding palliative care in mild or moderate dementia, to identify existing controversies, and to examine what are key components of palliative care in dementia, specifically when initiated earlier in the disease trajectory.

METHODS AND ANALYSIS

Consistent with recent guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we carried out a search for academic literature in PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, Web of Science; on 5 November 2019 and an updated search on 2 February 2021. We will include studies with different study designs published in English over the last decade that focused on palliative care in early stages of dementia. We will include models targeting at least one outcome domain of palliative care (physical, psychological, social or spiritual) and advance care planning, and will exclude hospice models with limited prognosis similar to the requirements in the USA. We will report study characteristics and quality. We aim to apply narrative synthesis techniques to develop a theoretical model of how, for whom and why palliative care can be relevant in early stages of dementia, and what are facilitators and barriers. We anticipate to also describe if and how the concept of (early) palliative care in dementia changed across time and studies.

ETHICS AND DISSEMINATION

No ethical review required. Results will identify research gaps and lay out basic principles for conceptualising palliative care in early stages of dementia.

Defining a good death for people with dementia: A scoping review

AIM

End-of-life care for people with dementia is becoming increasingly important as the global population ages. However, there is no agreed definition of a good death for people with dementia. The current review examined previous literature to establish the current state of knowledge on this issue.

METHODS

We conducted a scoping review using a standard methodological framework. Relevant studies were identified from four databases. Studies were included if they were in English, discussed palliative or end-of-life care for dementia, and defined or explained a good death. The definitions or explanations of a good death were categorized into subthemes, and grouped into broader themes.

RESULTS

We identified 11 articles discussing or explaining a good death in dementia, which were published between 2009 and 2017. Most of these studies drew on the views of healthcare professionals and/or family members of people with dementia, and only one considered the views of people with dementia themselves. Ten themes were identified, including pain-free status, peaceful/comfort, dignity, family presence, surrounded by familiar things and people, person-centered communication, spirituality, life completion, treatment preferences, and other.

CONCLUSIONS

The characteristics of a good death in dementia showed similarities with those identified more generally. However, there were some themes that were specific to end-of-life care in dementia, notably "surrounded by familiar things and people" and "person-centered communication". To obtain a fuller picture of the nature of a good death in dementia, researchers need to examine the views of people living with dementia.