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Cohn S, Borgstrom E, Driessen A. Not intervening as a form of care: Negotiating medical practices at the end-of-life. Med Anthropol Q 2024. [PMID: 39190643 DOI: 10.1111/maq.12881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 07/30/2024] [Indexed: 08/29/2024]
Abstract
Biomedicine is organized around interventions. Despite growing concern about overtreatment in healthcare systems, not intervening can still raise questions about potential negligence and the quality of care. Based on ethnographic fieldwork with palliative care teams in England, we explore the work palliative care specialists do to reduce and sometimes halt interventions for patients at the end-of-life, in a general medical environment that is largely interventionist. We describe how judgments about what is an action or not aren't based on obvious or agreed criteria, but ultimately according to what different actors feel constitutes the best form of care. In other words, the underlying values that shape ideas of care determine how action and inaction are nominated, and not the other way around.
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Affiliation(s)
- Simon Cohn
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Erica Borgstrom
- School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, UK
| | - Annelieke Driessen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Anthropology, University of Amsterdam, Amsterdam, Netherlands
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Samuels A, Lemos Dekker N. Palliative care practices and policies in diverse socio-cultural contexts: aims and framework of the ERC globalizing palliative care comparative ethnographic study. Palliat Care Soc Pract 2023; 17:26323524231198546. [PMID: 37706167 PMCID: PMC10496469 DOI: 10.1177/26323524231198546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/15/2023] [Indexed: 09/15/2023] Open
Abstract
Background Palliative care as a specialist professional practice of care for people with advanced illness is becoming increasingly influential worldwide. This process is affected by global health inequalities as well as cultural dimensions of approaching death and practicing care in life-limiting illness. Objectives The European Research Council-funded Globalizing Palliative Care (ENDofLIFE) project aims to understand how palliative care policies, discourses and practices are translated, adapted and reconstituted in diverse socio-cultural settings and how cultural dimensions of approaching death and local practices of care shape palliative care implementation. Methods and Analysis Using a multi-scalar and multi-sited ethnographic approach, the project uses person-centered ethnography, participant observation, semi-structured interviewing, focus group discussions and policy and discourse analysis at transnational, national and local levels. Ethnographic case-studies are conducted in Brazil, India and Indonesia. Discussion The globalizing palliative care project develops a novel ethnographic methodology of studying end-of-life care trajectories through long-term participant observation with individual patients and families as they manage and practice formal and informal health care in advanced illness. By analyzing how patients and families experience and navigate care over time, complemented by stakeholder interviews, the study advances critical theoretical insight into the relation between (large-scale and dynamically traveling) palliative care models, policies and discourses on the one hand and the experience and practice of palliative care in the lives of patients and informal care givers in local health care practices on the other hand. Insights are expected to benefit culturally situated palliative care policies and practices.
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Affiliation(s)
- Annemarie Samuels
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Leiden, The Netherlands
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French M, Keegan T, Preston N. Facilitating equitable access to hospice care in socially deprived areas: A mixed methods multiple case study. Palliat Med 2022; 37:508-519. [PMID: 36380483 PMCID: PMC10074748 DOI: 10.1177/02692163221133977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Maddy French
- Division of Health Research, Lancaster University, UK
| | | | - Nancy Preston
- Division of Health Research, Lancaster University, UK
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Whitelaw S, Bell A, Clark D. The expression of 'policy' in palliative care: A critical review. Health Policy 2022; 126:889-898. [PMID: 35840439 DOI: 10.1016/j.healthpol.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/24/2022] [Accepted: 06/26/2022] [Indexed: 11/30/2022]
Abstract
The importance of 'policy' within palliative care has steadily increased over the past 25 years. Whilst this has been welcomed within the palliative care field and seen as a route to greater recognition, we focus here on a more critical perspective that challenge the effectiveness of a 'policy turn' in palliative care. Applying Bacchi's "What's the Problem Represented to Be?" (WPR) framework to data from a systematic search, we address the research question, "in what ways has 'policy' been articulated in palliative care literature?". The paper describes the construction of 'the problem' context and reflects critically on the robustness and pragmatic utility of such representations. In particular, we identify five elements as prominent and problematic: (1) a lack of empirical evidence that connects policy to practice; (2) the dominance of 'Global North' approaches; (3) the use of a policy narrative based on 'catastrophe' in justifying the need for palliative care; (4) the use of idealistic and aspirational 'calls to action'; and (5) a disengaged and antagonistic orientation to existing health systems. We conclude by suggesting that the efficacy of palliative care policy could be enhanced via greater emphases on 'Global South' perspectives, 'assets-based' approaches and attention to pragmatic implementation.
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Affiliation(s)
- Sandy Whitelaw
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom.
| | - Anthony Bell
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Dumfries, DG1 4ZL, United Kingdom
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French M, Keegan T, Anestis E, Preston N. Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis. BMC Palliat Care 2021; 20:179. [PMID: 34802450 PMCID: PMC8606060 DOI: 10.1186/s12904-021-00878-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care. METHODS This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised. RESULTS Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care. CONCLUSION There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.
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Affiliation(s)
- Maddy French
- Division of Health Research, Lancaster University, Lancaster, UK.
| | - Thomas Keegan
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, UK
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Combes S, Forbes G, Gillett K, Norton C, Nicholson CJ. Development of a theory-based intervention to increase cognitively able frail elders' engagement with advance care planning using the behaviour change wheel. BMC Health Serv Res 2021; 21:712. [PMID: 34284759 PMCID: PMC8290869 DOI: 10.1186/s12913-021-06548-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Advance care planning (ACP) conversations support people to think about, discuss and document their beliefs, values and preferences regarding future care. This process means that should the person loose capacity in the future, care can be provided, consistent with their personal values and beliefs. The ACP process is particularly relevant for older people living with frailty (frail elders) as they are vulnerable to sudden deterioration. However, ACP is rarely undertaken by frail elders. The aim of this study was to develop an intervention to increase multidisciplinary health and social care professionals’ (H&SCPs) engagement of cognitively able, domestic-dwelling frail elders with ACP. Methods Intervention development was guided by the Medical Research Council framework for complex interventions and the Behaviour Change Wheel. Multiple methods were used to understand ACP barriers and enablers: a systematic integrative review, a survey (n = 73 H&SCPs), and semi-structured interviews (n = 10 frail elders, n = 8 family members). A conceptual model, developed from the integrative review, underpinned data collection for the survey and interviews. Synthesis of this data, including patient and public involvement, was then used to identify H&SCPs behaviours that needed to change for ACP to be implemented and decide content and implementation for the intervention. Results Following the Behaviour Change Wheel system, and based on the findings of the review, survey and interviews, the prototype intervention, Conversations on Living and Dying (CLaD), was developed. The CLaD prototype consisted of one 3.5-hour educational skills session for H&SCPs supported by a toolkit. Content focussed on the relevance of ACP for frail elders, experience of ACP by frail elders, and strategies H&SCPs could adopt to encourage frail elders’ engagement with ACP. Strategies include recognising the importance of relationships and living well now, preparing frail elders for ACP conversations and starting ACP early. Participants who took part in initial prototype refinement reported that the intervention helped them think differently about ACP and encouraged them to engage with frail elders. Conclusions The use of behavioural theory enabled the development of CLaD, an evidence-based, theory-driven, person-centred intervention to support ACP engagement with frail elders. While feasibility testing is required, initial prototype refinement demonstrated that H&SCPs found the intervention to be acceptable, engaging, and clinically valuable in their practice with frail elders and their families. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06548-4.
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Affiliation(s)
- S Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. .,St Christopher's Hospice, London, UK.
| | - G Forbes
- Centre for Behaviour Change, University College London, London, UK
| | - K Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - C J Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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Combes S, Gillett K, Norton C, Nicholson CJ. The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliat Med 2021; 35:1137-1147. [PMID: 33934669 PMCID: PMC8189003 DOI: 10.1177/02692163211013260] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The population of frail elders is growing, and due to their vulnerability to sudden deterioration, advance care planning is particularly important. However, advance care planning is uncommon for multiple reasons, some of which are linked to the perceptions of frail elders and their families. AIM To explore the barriers and enablers to advance care planning engagement with frail elders. DESIGN Qualitative in-depth interviews with thematic analysis. SETTING/PARTICIPANTS Purposive sample of 10 frail elders and 8 nominated family members using a community-based older persons' service run by a large urban UK hospice. Frail elders had capacity, were ⩾65 (median 85, range 71-95), scored 6 or 7 (median 6.5) on the Clinical Frailty Scale, and 70% were female. RESULTS Key barriers were: Advance care planning is unclear, in terms of meaning and the language used; Lack of relevance, with frail elders preferring to focus on living well now; and the Importance of family, relationships and home, and the influence of relationship on end of life decision-making. Engagement strategies included preparing the frail elder for advance care planning conversations and using a gentle, honest, individualised approach. CONCLUSIONS Essential enablers for frail elders are understanding what advance care planning is and why it may be relevant to them. For professionals, enablers include recognising the importance of living well now and relational decision-making. To further support advance care planning, recommendations include early engagement and re-conceptualising advance care planning as an ongoing process which encompasses current and future care. Further research is needed in different cultures and care contexts.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,St Christopher's Hospice, London, UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Caroline Jane Nicholson
- St Christopher's Hospice, London, UK.,Faculty of Health and Medical Sciences, Surrey University, Guildford, UK
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A Comparison of Policy Analysis of Palliative Care for Cancer in UK, Malaysia, and South Africa. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2019. [DOI: 10.5812/ijcm.94841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Dobson J. Providing high-quality care at the end of life: the role of education and guidance. ACTA ACUST UNITED AC 2019; 26:1116-1120. [PMID: 29125338 DOI: 10.12968/bjon.2017.26.20.1116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Palliative care in the UK has been ranked as the best in the world. So where did palliative care go so wrong that a 168-page document is required to inform staff how to care for dying patients if it has been going so well for so long? Those nearing the end of their life deserve to be given optimum care, attention, compassion and consideration, but this is not always the case. The Liverpool Care Pathway was a tool originally devised to help health professionals provide high-quality end-of-life care to people in the final phase of life. This tool, when used in the correct way, could provide the 'gold standard' of end-of-life care for patients. However, a national review found that rather than a tick-box exercise, care of the dying should be centred around individualised care planning for the dying patient, as highlighted in the publication of the guidance: One Chance to Get It Right. Care of the dying is a complex skill that requires nurses to provide some of the most challenging care, and for which many nurses have received little or no training. The implementation of this guidance into practice will require thoughtful change management, abandoning an old way of working in order to ensure excellence and high-quality care for patients nearing the end of life.
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Affiliation(s)
- Jill Dobson
- Senior Lecturer, Acute, Critical and Emergency Nursing, University of Central Lancashire, Preston
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10
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Combes S, Nicholson CJ, Gillett K, Norton C. Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model. Palliat Med 2019; 33:743-756. [PMID: 31057042 PMCID: PMC6620766 DOI: 10.1177/0269216319845804] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations. AIM To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development. DESIGN A structured integrative review of relevant literature. DATA SOURCES CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018. RESULTS From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality. CONCLUSION Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Caroline Jane Nicholson
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
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Wang SSC, Huang CM, Feng RC, Wu YL, Huang SJ. Validation of a concise screening tool for the identification of palliative care needs among inpatients: A prospective study in hospital setting. J Formos Med Assoc 2019; 118:883-890. [DOI: 10.1016/j.jfma.2018.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/19/2018] [Accepted: 10/03/2018] [Indexed: 10/27/2022] Open
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Germain L, Sabroe I. The care of dying people in 16th- and 17th-century England. DEATH STUDIES 2019; 44:270-277. [PMID: 30704341 DOI: 10.1080/07481187.2018.1541941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Between the years 1500 and 1700, mortality was higher and exposure to death is greater than in the modern day. Through analysis of primary texts from the chosen period, we explored the principles behind the care of the dying in the context of medicine, spirituality, and society. Results showed that a "holy death" was a cultural norm and medicine was subsidiary: hope was for the salvation of the soul, not the body. This was part of an approach that focused on symptom relief, irrespective of disease classification, demonstrating an early holistic approach to death and dying.
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Affiliation(s)
- Lewis Germain
- School of Medicine, University of Sheffield and Medical Humanities Sheffield, Sheffield, UK
| | - Ian Sabroe
- School of Medicine, University of Sheffield and Medical Humanities Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study. Lancet Gastroenterol Hepatol 2019; 4:52-62. [DOI: 10.1016/s2468-1253(18)30379-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
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Robinson J, Gott M, Gardiner C, Ingleton C. Specialist palliative care nursing and the philosophy of palliative care: a critical discussion. Int J Palliat Nurs 2017; 23:352-358. [PMID: 28756750 DOI: 10.12968/ijpn.2017.23.7.352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Nursing is the largest regulated health professional workforce providing palliative care across a range of clinical settings. Historically, palliative care nursing has been informed by a strong philosophy of care which is soundly articulated in palliative care policy, research and practice. Indeed, palliative care is now considered to be an integral component of nursing practice regardless of the specialty or clinical setting. However, there has been a change in the way palliative care is provided. Upstreaming and mainstreaming of palliative care and the dominance of a biomedical model with increasing medicalisation and specialisation are key factors in the evolution of contemporary palliative care and are likely to impact on nursing practice. Using a critical reflection of the authors own experiences and supported by literature and theory from seminal texts and contemporary academic, policy and clinical literature, this discussion paper will explore the influence of philosophy on nursing knowledge and theory in the context of an evolving model of palliative care.
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Affiliation(s)
- Jackie Robinson
- School of Nursing, University of Auckland, Auckland, New Zealand, Auckland District Health Board, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Clare Gardiner
- School of Nursing, University of Sheffield, Sheffield, United Kingdom
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Higginson IJ, Reilly CC, Bajwah S, Maddocks M, Costantini M, Gao W. Which patients with advanced respiratory disease die in hospital? A 14-year population-based study of trends and associated factors. BMC Med 2017; 15:19. [PMID: 28143520 PMCID: PMC5286738 DOI: 10.1186/s12916-016-0776-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in two common progressive respiratory diseases, and the impact of a national end of life care (EoLC) strategy to reduce deaths in hospital. METHODS This population-based observational study linked death registration data for people in England dying from chronic obstructive pulmonary disease (COPD) or interstitial pulmonary diseases (IPD). We plotted age- and sex-standardised trends, assessed during the pre-strategy (2001-2004), first strategy phase (2004-2008), and strategy intensification (2009-2014) periods, and identified factors associated with hospital death using multiple adjusted proportion ratios (PRs). RESULTS Over 14 years, 380,232 people died from COPD (334,520) or IPD (45,712). Deaths from COPD and IPD increased by 0.9% and 9.2% annually, respectively. Death in hospital was most common (67% COPD, 70% IPD). Dying in hospice was rare (0.9% COPD, 2.9% IPD). After a plateau in 2004-2005, hospital deaths fell (PRs 0.92-0.94). Co-morbidities and deprivation independently increased the chances of dying in hospital, with larger effects in IPD (PRs 1.01-1.55) than COPD (PRs 1.01-1.39) and dose-response gradients. The impact of multimorbidity increased over time; hospital deaths did not fall for people with two or more co-morbidities in COPD, nor one or more in IPD. Living in rural areas (PRs 0.94-0.94) or outside London (PRs, 0.89-0.98) reduced the chances of hospital death. In IPD, increased age reduced the likelihood of hospital death (PR 0.81, ≥ 85 versus ≤ 54 years); divergently, in COPD, being aged 65-74 years was associated with increased hospital deaths (PR 1.13, versus ≤ 54 years). The independent effects of sex and marital status differed for COPD versus IPD (PRs 0.89-1.04); in COPD, hospital death was associated with being married. CONCLUSIONS The EoLC strategy appeared to have contributed to tangible reductions in hospital deaths, but did not reach people with multimorbidity and this gap widened over time. Integrating palliative care earlier in the disease trajectory especially in deprived areas and cities, and where multimorbidity is present, should be boosted, taking into account the different demographic factors in COPD and IPD.
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Affiliation(s)
- Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Charles C. Reilly
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - Massimo Costantini
- Arcispedale Santa Maria Nuova-IRCCS, Viale Umberto I, 50 – 42123, Reggio Emilia, Italy
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
| | - on behalf of the GUIDE_Care project
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, Bessemer Road, London, SE5 9PJ UK
- Arcispedale Santa Maria Nuova-IRCCS, Viale Umberto I, 50 – 42123, Reggio Emilia, Italy
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Seymour J, Cassel B. Palliative care in the USA and England: a critical analysis of meaning and implementation towards a public health approach. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/13576275.2016.1270262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, the University of Sheffield, Barber House Annex, Sheffield, UK
| | - Brian Cassel
- Cancer Informatics, Massey Cancer Centre, Virginia Commonwealth University, Richmond, VA, USA
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Pollock K, Wilson E. Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03310] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAdvance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.AimTo investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.Design and data collectionQualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.SettingGeneral practices and community care settings in the East Midlands of England.FindingsThe study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.ConclusionsAdvance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.Future workAttention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Choice and compassion at the end of life: A critical analysis of recent English policy discourse. Soc Sci Med 2015; 136-137:99-105. [PMID: 25989003 DOI: 10.1016/j.socscimed.2015.05.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
End of life care in England has recently been framed by two very different discourses. One (connected to advance care planning) promotes personal choice, the other promotes compassionate care; both are prominent in professional, policy and media settings. The article outlines the history of who promoted each discourse from 2008 to early 2015, when, why and how and this was done. Each discourse is then critically analysed from a standpoint that takes account of bodily decline, structural constraints, and human relationality. We focus on the biggest group of those nearing the end of their life, namely frail very old people suffering multiple conditions. In their care within contemporary healthcare organisations, choice becomes a tick box and compassion a commodity. Informed choice, whether at the end of life or in advance of it, does not guarantee the death the person wants, especially for those dying of conditions other than cancer and in the absence of universally available skilled and compassionate care. Enabling healthcare staff to provide compassionate, relational care, however, implies reversing the philosophical, political and financial direction of healthcare in the UK and most other Anglophone countries.
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Cooper J, Kierans C. Organ donation, ethnicity and the negotiation of death: ethnographic insights from the UK. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/13576275.2015.1021314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Early integration of palliative care in hospitals: A systematic review on methods, barriers, and outcome. Palliat Support Care 2014; 12:495-513. [DOI: 10.1017/s1478951513001338] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:According to the World Health Organization (WHO), palliative care (PC) should be available to everyone suffering from life-threatening diseases and should be started early on in the illness trajectory. However, PC is often initiated much later and is restricted to cancer patients. There is a need for more knowledge about how early PC can be implemented in clinical practice. The purpose of our study was to document the best evidence on methods for early identification (EI) of palliative trajectories in cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) populations, and to identify preconditions for early integration of general PC in hospitals and outcomes for patients and relatives.Method:A comprehensive systematic review of methods, preconditions, and outcomes was conducted via an electronic literature search of publications between 2002 and September 2012. A final sample of 44 papers was reviewed in detail.Results:Our study identified disease-specific and general methods for EI of patients who might benefit from PC. Prognostication of end-stage disease based on (holistic) clinical judgment, prognostic factors, and/or care needs are the most frequently recommended methods. A number of interacting disease-, staff-, user-, and organization-specific barriers need to be overcome in order to implement early integration of PC in clinical practice. Early integration of PC may lead to better symptom management, prolonged survival, and better quality of life.Significance of Results:No methods can be recommended for routine clinical practice without further validation. There is an urgent need to develop and evaluate methods based on the holistic assessment of symptoms or needs. The barriers to early integration of PC are most extensive with regard to CHF and COPD. Professional training and education are recommended to facilitate early implementation of PC. The evidence about outcome is sparse and mostly relates to cancer populations receiving specialized PC.
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Cassel JB. The importance of following the money in the development and sustainability of palliative care. Palliat Med 2013; 27:103-4. [PMID: 23381145 DOI: 10.1177/0269216312473218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J Brian Cassel
- Division of Hematology, Oncology and Palliative Care, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
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