Living through the end: The phenomenon of dying at home

Factors associated with grief in informal carers of people living with Motor Neuron Disease: A mixed methods systematic review

The purpose of this mixed methods systematic review was to identify factors associated with anticipatory grief, post-death grief, and prolonged grief in informal carers of people living with Motor Neuron Disease (MND) to inform future research and practice. Six electronic databases were searched and two quantitative and eight qualitative studies were identified. Five overarching themes were generated through thematic synthesis. The findings suggest that there are factors that may affect different grieving processes. It might be particularly important to target some factors prior and after the death of the person living with MND such as the knowledge about the progression of the disease, changes in relationships, anxiety and depressive symptoms of carers, and planning for death of the care recipient. Factors that may affect all three grieving processes were also identified such as negative experiences of caregiving, experiences of losses, end of life and psychological support, and emotional avoidance coping.

'The beauty and the less beautiful': exploring the meanings of dying at 'home' among community and practitioner representatives and advocates across Canada

Background

Significant structural and normative pressures privilege the ideal of dying at home in Canada. At the same time, the social complexities and meanings associated with dying in particular locations remain critically unexamined.

Objective

The aim of this study is to explore how diverse community members, including health and social care stakeholders, talk about preferences for locations of dying, with a particular focus on meanings of dying at home.

Design

Semi-structured virtual interviews were conducted with 24 community and practitioner representatives and advocates across Canada during the Covid-19 pandemic. This included compassionate community advocates, palliative care professionals and volunteers, bereaved carers, and members of queer, rural, and immigrant communities. Participants were asked about their own preferences for location of dying and elaborated on these aspects with regard to their client population or community group.

Results

Our analysis illuminates how meanings of dying at home are connected to previous experiences and perceptions of institutional care. As such, participants' perspectives are often framed as a rejection of institutional care. Dying at home also often signals potential for preserving ontological security and relational connection in the face of life-threatening illness. However, participants' expertise simultaneously informs a sense that dying at home is often unattainable. At times, this awareness underpins interpretations of both preferences and choices as contingent on considerations of the nature and type of illness, concerns about impacts on families, and available resources.

Conclusion

The ideal of dying at home is nuanced by identity, relational, and structural contexts. Knowledge from this study can inform realistic and practical person-centered planning across care settings. It can also help create more representative public policy and health system quality indicators regarding a 'good death' that do not rely on or perpetuate undeveloped and unrealistic assumptions about dying, home, and family care.

Preferred Place of Death in Adult Cancer Patients: A Systematic Review and Meta-Analysis

Background: Identifying the preferred place of death is a key indicator of the quality of death in cancer patients and one of the most important issues for health service policymakers. This study was done to determine the preferred place of death and the factors affecting it for adult patients with cancer.

Methods: In this systematic review and meta-analysis study four online databases (PubMed, Scopus, web of science, ProQuest) were searched by relevant keywords. Quality assessment of papers was conducted using Newcastle-Ottawa (NOS) criterion. Odds ratios, relative risks, and 95% confidence intervals were determined for each of the factors extracted from the investigations.

Results: A total of 14,920 participants of 27 studies were included into the meta-analysis. Based on the results, 55% of cancer patients with a confidence interval [95% CI (41–49)] preferred home, 17% of patients with a confidence interval [95% CI (−12%) 23)] preferred hospital and 10% of patients with confidence interval [95% CI (13–18)] preferred hospices as their favored place to die. Effective factors were also reported in the form of demographic characteristics, disease-related factors and psychosocial factors.

Conclusions: This study showed that more than half of cancer patients chose home as their preferred place of death. Therefore, guided policies need to ensure that the death of the patients in the preferred place should be considered with priority.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020218680, identifier: CRD42020218680.

The experiences of, and need for, palliative care for people with motor neurone disease and their informal caregivers: A qualitative systematic review

BACKGROUND

Despite being a terminal neurodegenerative disease, the role of palliative care is less recognised for motor neurone disease than for other life-limiting conditions. Understanding the experiences of, and need for, palliative care for patients and carers is key to configuring optimal policy and healthcare services.

AIM

To explore the experiences of, and need for, palliative care of people with motor neurone disease and their informal carers across the disease trajectory.

DESIGN

A systematic review of qualitative research conducted using Thematic Synthesis - PROSPERO registration CRD42017075311.

DATA SOURCES

Four electronic databases were searched (MEDLINE, CINAHL, PsycINFO, Social Science Citation Index) using terms for motor neurone disease, amyotrophic lateral sclerosis, palliative care, and qualitative research, from inception to November 2018. Included papers were data extracted and assessed for quality.

RESULTS

A total of 41 papers were included, representing the experiences of 358 people with motor neurone disease and 369 caregivers. Analytical themes were developed detailing patients' and carers' experiences of living with motor neurone disease and of palliative care through its trajectory including response to diagnosis, maintaining control, decision-making during deterioration, engaging with professionals, planning for end-of-life care, bereavement.

CONCLUSION

The review identified a considerable literature exploring the care needs of people with motor neurone disease and their carers; however, descriptions of palliative care were associated with the last days of life. Across the disease trajectory, clear points were identified where palliative care input could enhance patient and carer experience of the disease, particularly at times of significant physical change.

Making her end of life her own: further reflections on supporting a loved one with motor neurone disease

BACKGROUND

People can live for many months without knowing why their body is failing prematurely before being diagnosed with motor neurone disease (MND); a terminal neurodegenerative disease which can be experienced as 'devastating' for the person and their family.

AIM

This study aimed to explore the meaning of supporting a loved one with MND to die.

METHODS

This study uses reflection and autobiographical story to connect with broader cultural, political and social meaning and understandings of dying.

FINDINGS

Four themes were identified relating to the end-of-life trajectory of MND. Loss of person (lived body experienced in silence); loss of relationships (lived relations are challenged); loss of home and loss of time (lived space and lived time take on new meaning); loss of future (dying-facing it alone).

CONCLUSION

Dying with MND is a complex phenomenon. When a person can no longer move and communicate, relationships between those involved in end-of-life care are challenging. A person with MND needs the support from those acting as power of attorney to make their end of life their own, and they themselves need support to find meaning in their suffering. This autoethnographic reflection provides vicarious experiences for nurses and other healthcare professionals working with people with MND and similar conditions.

A qualitative inquiry into the barriers and facilitators to achieving home death

OBJECTIVES

To explore the barriers and facilitators to patients achieving death at home.

METHODS

In-depth, semistructured interviews with end-of-life care experts were conducted to develop an insight into the barriers and facilitators to achieving death at home. Thirty-three interviews were conducted compromising of a mixture of face-to-face and tele interviews. Experts included healthcare professionals working in the community, hospital and policy/academic settings. Thematic analysis was undertaken on interview transcripts.

RESULTS

Three overarching themes, further divided into a total of 12 subthemes were identified. The three themes were 'managing people', 'education' and 'planning'. The 'managing people' theme included subthemes of patient preferences and family influences; the 'education' theme encompassed knowledge and training, perceptions of death and communication and the 'planning' theme contained seven subthemes including 'coordination', 'resources' and 'cost'.

CONCLUSIONS

Multiple barriers and facilitators to achieving death at home were identified in this study. Of particular significance was the identification of the fear and stigma associated with death among doctors, patients and their families serving as a barrier to home death, not previously identified in the literature. Additionally, the importance of social networks and resource provision were highlighted as key in influencing patient death at home.