Cancer Decedents' Hospital End-of-Life Care Documentation: A Retrospective Review of Patient Records

Objective: International standards of end-of-life care (EOLC) intend to guide the delivery of safe and high-quality EOLC. Adequately documented care is conducive to higher quality of care, but the extent to which EOLC standards are documented in hospital medical records is unknown. Assessing which EOLC standards are documented in patients' medical records can help identify areas that are performed well and areas where improvements are needed. This study assessed cancer decedents' EOLC documentation in hospital settings. Methods: Medical records of 240 cancer decedents were retrospectively evaluated. Data were collected across six Australian hospitals between 1/01/2019 and 31/12/2019. EOLC documentation related to Advance Care Planning (ACP), resuscitation planning, care of the dying person, and grief and bereavement care was reviewed. Chi-square tests assessed associations between EOLC documentation and patient characteristics, and hospital settings (specialist palliative care unit, sub-acute/rehabilitation care settings, acute care wards, and intensive care units). Results: Decedents' mean age was 75.3 years (SD 11.8), 52.0% (n = 125) were female, and 73.7% lived with other adults or carers. All patients (n = 240; 100%) had documentation for resuscitation planning, 97.6% (n = 235) for Care for the Dying Person, 40.0% for grief and bereavement care (n = 96), and 30.4% (n = 73) for ACP. Patients living with other adults or carers were less likely to have a documented ACP than those living alone or with dependents (OR 0.48; 95% CI 0.26-0.89). EOLC documentation was significantly greater in specialist palliative care settings than that in other hospital settings (P < .001). Conclusion: The process of dying is well documented among inpatients diagnosed with cancer. ACP and grief and bereavement support are not documented enough. Organizational endorsement of a clear practice framework and increased training could improve documentation of these aspects of EOLC.

Clinician Communication in Hospice: Constructions of Reality Throughout the End-of-Life Process

The current study examined qualitative data from hospice clinicians' perspectives on language, surrounding end-of-life (EOL), to understand challenges and opportunities for constructing a trajectory of communication leading towards a good death experience. Findings from two focus groups with nine clinicians' and 12 individual interviews, four of which were follow up interviews after the focus groups, were guided by framework analysis and revealed three themes, constructing language choices, roles and responsibilities, and socio-cultural considerations. We used the Opportunity Model for Presence during the End-of-Life Process (OMP-EOLP) to make sense of the findings and discuss implications for language use throughout the EOL process. We argue additional efforts should be made in recognizing the value of presence checks, re-constructing advance care planning, and utilizing different forms of media as an educational tool and connection mechanism for clinicians with patients and families to achieve a timely engagement of EOL conversations for all healthcare participants.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

"Maintaining hope:" challenges in counseling latino patients with advanced cancer

BACKGROUND

Latino cancer patients are at risk of poor psychological adjustment. Therapeutic effectiveness in treating Latino cancer patients with advanced cancer requires managing distress, therapeutic skill, and cultural competency. This mixed-methods study explored mental health providers' perceptions of the challenging aspects of counseling and caring for Latino patients with advanced cancer.

METHODS

Mental health providers providing services to Latino or Hispanic cancer patients received an emailed web-based survey with open- and closed-ended questions. Providers included psychiatrists, psychologists, social workers, counselors, and other mental health professionals. We invited 154 providers to participate from July 2015 to January 2017. One hundred and four accessed the survey, and 66 eligible providers responded, for a response rate of 43%. Analyses were used to explore whether clinical experience factors and training characteristics were associated with perceiving conversations about cancer (diagnosis, prognosis, and end-of-life) as challenging. Second, the challenging aspects of these conversations were explored qualitatively. Four independent coders coded responses; an inductive content analysis was utilized to analyze the data.

RESULTS

Mental health providers describe encountering many challenges in their therapeutic discussions with Latino cancer patients.

CONCLUSIONS

It is imperative to understand the factors associated with the perceived difficulty of these conversations, as well as the characteristics of these conversations, to develop culturally sensitive interventions and programs for patients and training interventions for providers.

Análisis situacional de los psicólogos de cuidados paliativos

Introducción. Los pacientes con enfermedades crónicas en fase avanzada tienen numerosas necesidades psicológicas, sociales y espirituales, como resultado de su estado físico, condición, curso terapéutico y efectos secundarios del tratamiento, además de distrés psicológico y existencial por lo que la figura del psicólogo en Cuidados Paliativos tiene una gran relevancia. Objetivo. Realizar un análisis situacional de los psicólogos integrados a los equipos de cuidados paliativos del sector público en México. Método. Estudio prospectivo, descriptivo y transversal. Se diseño una encuesta ex profeso de 22 reactivos con respuesta dicotómica y opción múltiple. Resultados. Se analizaron un total de 49 encuestas de psicólogos que prestan sus servicios en unidades de atención médica en México, a través de análisis de frecuencias y porcentajes, chi cuadrada y w de wilcoxon. Conclusiones. Los psicólogos en cuidados paliativos requieren formación y capacitación formal para desarrollar habilidades y competencias específicas en este contexto; y de mayor sistematización y de protocolos de manejo en las evaluaciones e intervenciones psicológicas en el paciente de cuidados paliativos y su familia para evidenciar la contribución de la Psicología en Cuidados Paliativos.

Nurses practice towards palliative care in Shire Endasilasie health facilities, Northern Ethiopia: a cross-sectional study

Introduction

The public health strategy of the World Health Organization for palliative care is to increase access to palliative care services by integrating it with the healthcare systems. Therefore, the value of palliative care service provision by nurses who deliver the majority of care to chronical patients is an important issue. The objective of the study is assessing nurses' practice of palliative care.

Methods

A facility based cross-sectional study was carried out among 278 nurses working in governmental health facilities of Shire Endasilasie town, Tigray region, Ethiopia from February to June 2018. The questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. The final result was reported using text and tables.

Results

A total of 278 nurses were included in the study and the response rate was 100%. The majority of the participants (71.9%) were females and the mean age of the respondents was 32.08 years (range from 20 to 60). Approximately two-thirds (74.8%) of the respondents had poor knowledge of palliative care practice. Half of the study participants reported emotional support gained as primary psychological support. Commonly used drugs for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8% nurses focus on quality patient pain assess.

Conclusion

The majority of the nurses had a poor practice of palliative care.

Mental healthcare and palliative care: barriers

CONTEXT

Psychological symptoms are common among palliative care patients with advanced illness, and their effect on quality of life can be as significant as physical illness. The demand to address these issues in palliative care is evident, yet barriers exist to adequately meet patients' psychological needs.

OBJECTIVES

This article provides an overview of mental health issues encountered in palliative care, highlights the ways psychologists and psychiatrists care for these issues, describes current approaches to mental health services in palliative care, and reviews barriers and facilitators to psychology and psychiatry services in palliative care, along with recommendations to overcome barriers.

RESULTS

Patients in palliative care can present with specific mental health concerns that may exceed palliative care teams' available resources. Palliative care teams in the USA typically do not include psychologists or psychiatrists, but in palliative care teams where psychologists and psychiatrists are core members of the treatment team, patient well-being is improved.

CONCLUSION

Psychologists and psychiatrists can help meet the complex mental health needs of palliative care patients, reduce demands on treatment teams to meet these needs and are interested in doing so; however, barriers to providing this care exist. The focus on integrated care teams, changing attitudes about mental health, and increasing interest and training opportunities for psychologists and psychiatrists to be involved in palliative care, may help facilitate the integration of psychology and psychiatry into palliative care teams.

Grief over patients, compassion fatigue, and the role of social acknowledgment among psycho-oncologists

OBJECTIVE

Compassion fatigue-that is, secondary traumatic stress (STS) and burnout-is a traumatic emotional state experienced by health care providers and expressed in a reduced capacity to be interested in and empathic to the suffering of others. Compassion fatigue may be related to grief over patients' loss. We examined the relation between grief and compassion fatigue among psycho-oncologists while exploring the impact of social acknowledgment on this association. We hypothesized that social acknowledgment would moderate the relation between grief and compassion fatigue.

METHODS

Participants were 60 Israeli psycho-oncologists in a cross-sectional study. Measures consisted of a demographic questionnaire, the Texas Revised Inventory of Grief-Present, the Social Acknowledgment questionnaire, and the Professional Quality of Life Questionnaire.

RESULTS

The participants reported relatively high levels of grief and high levels of compassion fatigue. Grief and compassion fatigue were significantly positively associated (STS: r = 0.41, p < 0.01; Burnout: r = 0.45, p < 0.01). A k-means cluster analysis based on social acknowledgment and grief yielded three meaningful clusters: High Grief-Low Social Acknowledgment; Medium Grief-High Social Acknowledgment; and Low Grief-Medium Social Acknowledgment. Levels of STS in the first cluster were significantly higher in comparison to levels of STS in each of the other clusters (F = 6.22, p < 0.01).

CONCLUSIONS

Psycho-oncologists experience patient loss as part of their daily work. In response, they may develop grief reactions. This grief, when it is not perceived by them as being socially acknowledged, may result in high levels of STS: a phenomenon with undesirable personal and professional implications.

Primary Care for the Elderly Bereaved: Recommendations for Medical Education

The aim of this study was to explore the current practices of primary care physicians (PCPs) in providing bereavement care to elderly patients, with implications for medical education. A total of 63 PCPs answered a brief online survey about their typical practices, barriers, comfort level with bereavement, and confidence in their ability to diagnose prolonged grief disorder (PGD). They were recruited through an online newsletter and contacts of one of the authors. The results found that two-thirds of the PCPs do not routinely screen their elderly patients for recent losses, nor do they refer to mental health clinicians when loss is identified. Barriers included not learning of the deaths in patients' lives and lack of time during clinic visits. Those PCPs who had experienced their own losses were significantly more comfortable in speaking to patients about recent losses and more confident in their ability to diagnose PGD. We recommend bereavement education be incorporated into the medical school curriculum from the outset, utilizing the psychological principle of graded exposure to bereaved individuals.

Enhancing Meaning when Facing Later Life Losses

OBJECTIVE

This article presents several client cases to illustrate psychotherapeutic interventions for helping older adults facing later life losses enhance their sense of meaning.

METHODS

Cases are derived from the client population of a community mental health clinic which provides psychotherapy for low income, seriously mentally ill, culturally diverse older adults, many of whom experience serious medical illnesses. Over the course of 24 years in this setting, the primary author has observed various interventions which offer possibilities to provide hope and meaning for clients with severe problems.

RESULTS

Interventions discussed with individual cases include utilizing life review and reminiscence therapies, helping in grappling with the ending of life, facilitating enhanced relationships, encouraging creative endeavors, enabling spiritual and religious practices, honoring wisdom and legacy leaving, and engaging in mindfulness practices. Each approach is reviewed with reference to empirical support, clinical utility, and treatment considerations.

CONCLUSIONS

Helping older adults to find hope and meaning in their lives can be challenging. Specific interventions which target meaning-making may be adapted to fit each client's needs.

CLINICAL IMPLICATIONS

Clinicians may focus on enhancing meaning as a core or adjunct aspect of treatment with older adult clients. Considerations for implementing interventions may depend on contextual factors relevant to each case.

Contemporary psychological approaches to life at the end of life

When people have a serious life-limiting illness, physical symptoms are often prominent, both in the experience of the illness and in its treatment. No less important, however, are psychological symptoms. A holistic, bio-psycho-social-spiritual approach to quality of life near the end of life must address psychological distress of all types, including frank psychopathology, more moderate problems with living, and existential distress. Responding to mental health issues at the end of life requires (1) systematic and careful assessment, and (2) deployment of evidence-based treatments. In recent years, standardized assessment tools have been adapted or developed for use with people who have serious illness, and the same has happened with psychological treatments. Practitioners have several resources available to them. Given their practice orientation centered on meaningful engagement, occupational therapists can play an important role in responding to mental distress in patients with serious illness whose lives are becoming more circumscribed because of their medical condition or because of the mental distress itself. High-quality end-of-life care depends on scrupulous attention to the full spectrum of thoughts, feelings, and behaviors that unfold as death draws near.

Psychosocial Care and the Role of Clinical Psychologists in Palliative Care

Objectives:

The aim of this study was to explore the works of clinical psychologists in palliative care in Taiwan.

Methods:

Clinical psychologists who were working or had experience in palliative care were recruited. A 2-stage qualitative method study was conducted, including semistructured interviews and a focus group.

Results:

The following 4 main themes were identified: (1) the essential nature of the psychologists’ care were caring and company; (2) the dynamic process included psychological assessment, intervention, and evaluation based on psychological knowledge; (3) they needed to modify their care using an integrative framework, by setting practical goals and using techniques with flexibility; and (4) they faced external and internal challenges in this field.

Conclusion:

Clinical psychologists have beneficial contributions but have to modify psychosocial care based on the patients’ needs and clinical situations.

ACE Project--advocating for clinical excellence: creating change in the delivery of palliative care

BACKGROUND

Psychologists, social workers, and spiritual care professionals report inadequate preparation to maximize their effectiveness in advocating for institutional reform to meet oncology patients' diverse bio-psychosocial-spiritual and cultural needs. This article provides an overview of the ACE Project, a National Cancer Institute, 5 year, R25-funded transdisciplinary palliative care education program designed to enhance the advocacy and leadership skills of 301 competitively selected psycho-oncology professionals.

METHODS

ACE Project participants identified an institutional goal, refined their goals during the course and received mentorship and support throughout the subsequent year. Participants were invited to return to a Reunion Conference in year five to report on their activities, network, and share the results of their change efforts. A subset of 28 ACE Project participants contributed to this OMEGA special issue.

RESULTS

Participants' goals primarily focused on strategies to improve clinical care through program development and improvements in palliative care education within their institutions.

CONCLUSIONS

The results of this transdisciplinary leadership skills-building program for psycho-oncology professionals affirm the feasibility and perceived need for the program. See the ACE Project website (http://www.cityofhope.org/education/health-professional-education/nursing-education/ACE-project/Pages/default.aspx) for additional program information.

Exploring perceptions of psychological services in a children's hospice in the United Kingdom

BACKGROUND

The provision of emotional and psychological support for all family members who need it is an essential element of holistic palliative care. Within East Anglia's Children's Hospice, teams of professionally trained and experienced workers offer psychosocial support to all family members at all times during the child's and family's journey. However, the effectiveness and appropriateness of current psychosocial provision is unclear, as is the requirement for any additional psychological services.

OBJECTIVE

The purpose of this study was to elicit perceptions about current psychological support within the hospice from a group of stakeholders (parents, hospice staff, and external professionals).

METHOD

Forty-five parents participated in family focus groups, telephone interviews, individual interviews in their home, or a web-based survey. Ninety-five hospice staff (including nurses, carers, play specialists, therapists, and family support practitioners) and 28 external staff (including physicians, nurses, and commissioning managers) were seen using a mixture of focus group and individual meetings. Focus groups and meetings were held at the hospice building or at an external venue. Interviews were recorded and transcribed verbatim and analyzed using thematic coding.

RESULTS

Two main themes addressing perceptions of current psychological provision emerged: "understanding psychological support" and "unmet psychological need." Subthemes linked to support included choice, staff roles and labels, communication, and flexibility, whereas the themes within unmet need had a stronger focus on people and problems.

SIGNIFICANCE OF RESULTS

Understanding different user perspectives is an important first step in enhancing current psychological provision; operationalizing the findings will be challenging.

Posttraumatic stress disorder at the end of life: extant research and proposed psychosocial treatment approach

According to some estimates, 84% of people experience a traumatic event during their lives (Vrana & Lauterbach, 1994), and 15% to 24% then develop posttraumatic stress disorder (PTSD). Many carry with them lasting effects of trauma as they age and enter the last phase of life. PTSD manifests in unique ways at the end of life, possibly disrupting factors associated with a positive dying process, including social support, medical communication, life review, and acceptance of death. Terminally ill people with PTSD may suffer more emotional distress, lower quality of life, and poorer medical prognosis than those without PTSD. Unfortunately, healthcare providers may not be trained to address this issue. This article reviews the literature concerning how PTSD may affect the end of life and proposes an intervention model based on a palliative care philosophy.

Death beliefs and practices from an Asian Indian American Hindu perspective

The purpose of this article was to explore Asian Indian American Hindu (AIAH) cultural views related to death and dying. Three focus group interviews were conducted with AIAH persons living in the southern region of United States. The focus group consisted of senior citizens, middle-aged adults, and young adults. Both open-ended and semistructured questions were asked to elicit discussions that would uncover the meanings respondents attribute to death, as well as their pre- and post-death practices. All the sessions were tape recorded. Two independent researchers examined the transcripts of the 3 sessions and generated common themes. The results of this qualitative study indicate that all 3 generations were believers in the afterlife and the karmic philosophy. However, they exhibited differences in the degree to which Hindu traditions surrounding death and bereavement have been influenced by the fact that they live in the United States. Implications for service providers are included.

Reducing the risk of burnout in end-of-life care settings: the role of daily spiritual experiences and training

OBJECTIVE

Individuals in the helping professions are subject to unique stressors that may lead to burnout, and research has shown that those who work with dying or bereaved individuals might be particularly at-risk. This study explores how factors such as spirituality and level of training might buffer the stress of working with terminally ill clients and their families.

METHOD

A total of 80 medical and mental health practitioners attending palliative care seminars were surveyed, with each completing validated measures of daily spiritual experiences and caregiver burnout, as well as assessments of demographic factors, their general education and training experiences specific to working in end-of-life care and bereavement settings.

RESULTS

Findings indicate that daily spiritual experiences might mitigate physical, cognitive, and emotional forms of burnout in the workplace. In addition, a negative correlation was found between the amount of end-of-life training received and burnout in the physical and cognitive domains. However, training was not related to professionals' level of emotional exhaustion.

SIGNIFICANCE OF THE RESEARCH

Results reinforce a growing literature on the salutary effects of spirituality, and underscore its relevance as one possible form of constructive coping for professionals attending to the needs of the dying and bereaved. The study carries further implications for how the stresses of such work might be ameliorated by enhanced training efforts, as well as creative facilitation of diverse spiritual expressions (e.g., inclusive forms of ritual recognition of loss) in the workplace.

Becky's legacy: more lessons

In this commentary on Werth's (this issue) article, the author attempts to continue the work of "meaning making" by describing 10 lessons that were evident to him, based on 25 years of experience as an end-of-life researcher and clinician. He highlights the impact of stress, the importance of communication, the idiosyncratic definition of a "good death," the role of patient-centered care, the power of self-efficacy, the need to integrate theory and experience, the use of interdisciplinary teams, the impact of altruism and having a sense of purpose, the need to listen, and the healing effects of communicating about loss.

Patient as teacher

The author provides some reflections based on her experiences as a member of Becky's treatment team (see Werth, this issue). She briefly highlights some of the areas that were most important in her work with Becky and others with life-limiting illnesses, including information-seeking, social support, maintaining normalcy, depression and decision-making, nausea and vomiting, post-traumatic stress disorder, and the role of psychotherapy. She ends with her reactions to working with Becky and how Becky touched her personally and professionally.

A critical analysis of criticisms of the Oregon Death with Dignity Act

This article critically examines the validity of common criticisms of the Oregon Death with Dignity Act, primarily through reviewing published research and analyses. After summarizing the law and recent developments, 11 areas of concerns are examined: (a) the amount of data collected, (b) the availability of the data, (c) the reporting process, (d) protection of physicians, (e) terminal illness as a requirement, (f) the amount of data on palliative care interventions, (g) data on lethal prescriptions, (h) data on psychological/psychiatric evaluations, (i) whether the decision to request medication is informed, (j) whether the request is voluntary, and (k) financial factors. The authors examine each of these areas of concern and find criticisms to be unfounded given the research and analyses conducted to date.

Psychological research on death attitudes: an overview and evaluation

One of the most substantial legacies of Herman Feifel was his pioneering research on attitudes toward death and dying in a variety of populations. The authors review the large and multifaceted literature on death anxiety, fear, threat and acceptance, focusing on the attitudes toward death and dying of relevant professional and patient groups, and the relationship of death concern to aging, physical and mental health, religiosity, and terror management strategies. We conclude with several recommendations for improving the conceptual and practical yield of future work in this area.