The contemporary relevance of Glaser and Strauss

Health care professional recruitment of patients and family carers to palliative care randomised controlled trials: A qualitative multiple case study

BACKGROUND

Trial participant recruitment is an interactional process between health care professionals, patients and carers. Little is known about how clinicians carry out this role in palliative care trials and the reasons why they do or do not recruit participants.

AIMS

To explore how clinicians recruit to palliative care trials, why they choose to implement particular recruitment strategies, and the factors that influence their choices.

DESIGN

A qualitative multiple case study of three UK palliative care trials. Data collection included interviews and study documentation. Analysis involved developing and refining theoretical propositions, guided by the '6Ps' of the 'Social Marketing Mix Framework' as an a priori framework (identifying participants, product, price, place, promotion and working with partners). Framework Analysis guided within and then cross-case analysis.

SETTINGS/PARTICIPANTS

Study investigators and research staff (n = 3, 9, 7) from trial coordinating centres and recruitment sites (hospice and hospital).

RESULTS

Cross-case analysis suggests the 'Social Marketing Mix Framework' is useful for understanding recruitment processes but wider contextual issues need to be incorporated. These include the 'emotional labour' of diagnosing dying and communicating palliative and end-of-life care to potential participants and how the recruitment process is influenced by the power relationships and hierarchies that exist among professional groups. These factors can lead to and support paternalistic practices.

CONCLUSIONS

Those planning trials need to ensure that trial recruiters, depending on their experience and trial characteristics, have access to training and support to address the 'emotional labour' of recruitment. The type of training required requires further research.

Transformation of the concepts and practice of total pain and total care: 30 years of Danish hospices

The concept of total pain endeavors to encompass central aspects of suffering in relation to severe disease, death and dying. Dame Cicely Saunders introduced the concept in the early 1960s in relation to care for the terminally ill and dying patients with cancer. An examination of Danish palliative care, particularly Danish hospice care, indicates that total pain continues to be a relevant concept today. To further explore the current relevance of total pain the study examines its underlying ontology, epistemology and methodology. The study also addresses how the understanding and practice of total pain theory has developed throughout its history, in addition to how the understanding of concepts and practices is constantly being negotiated, shaped and transformed in relation to changes in society and by individuals, groups and organizations. The first of 21 hospices in Denmark opened in 1992 and they represent a case in point for exploring the transformation of total pain and total care since then. The empirical data, which are based on materials relevant to the history of the hospice movement and practice in Denmark, include national policy documents, local yearbooks, mapping, research, documentation of practice, interviews and on-going dialogue with management and staff at Danish hospices over the last 25 years. The study, which takes an abductive analytical approach, draws on my own experiences and empirical data, in addition to the empirical and theoretical research of others but also gains inspiration from a theoretical institutional logic perspective. Research shows that there are three main co-existing and interrelated institutional logics in the history of Danish hospices: care, medicine and governance. Based on inspiration from sociological and philosophical palliative care research and data on the development of Danish hospices, this study demonstrates how the concepts and practices of total pain and total care have been transformed in the compromises made due to the co-existence of these competing logics.

End-of-life conversation from both sides of the bed: voices of family and staff

PURPOSE

Prolonged living with chronic illness and disability expands the discussion of end-of-life conversation because of the complex role of intercommunication among patient, family, and healthcare staff. Little is known about such interaction from participants' different perspectives. This qualitative case study examined end-of-life conversation among patient, family, and staff during long-term hospitalization in a neurological rehabilitation department.

METHODS

After the patient's death, 18 participants responded to in-depth semi-structured interviews: 16 healthcare staff and two family members (the patient's wife and brother). In addition, we used the wife's autoethnographic documentation of her experiences during end-of-life conversation.

RESULTS

Thematic analysis produced three themes: (1) The Rehabilitation Department's Mission - Toward Life or Death? (2) The Staff's Perception of the Patient; (3) Containing Death: End-of-life Conversation from Both Sides of the Bed. These themes represented participants' different perspectives in the intercommunication in overt and covert dialogues, which changed over time. Death's presence-absence was expressed by movement between clinging to life and anticipating death.

CONCLUSION

The study findings emphasize the importance of practitioners' training to accept and openly discuss death as an inseparable part of life-long disability, and the implementation of this stance during end-of-life care via sensitive conversations with patients and their families.IMPLICATIONS FOR REHABILITATIONIt is vital for rehabilitation professionals to be trained to process and accept end-of-life issues as a natural and inseparable part of the life discourse among people with disabilities and their families.Rehabilitation professionals need to acquire tools to grasp the spoken and unspoken issues related to life and death, and to communicate their impressions and understandings with people with disabilities and their families.Rehabilitation professionals need to encourage an open dialogue when communicating with people with disabilities and their families on processes related to parting and death.

Should Human Rights and Autonomy be The Primary Determinants for the Disclosure of a Decision to Withhold Futile Resuscitation?

Do not attempt cardiopulmonary resuscitation decisions (DNACPR) are considered good medical practice for those dying at the end of natural life. They avoid intrusive and inappropriate intervention. Historically, informing patients of these decisions was discretionary to avoid undue distress. Recent legal rulings have altered clinical guidance: disclosure is now all but obligatory. The basis for these legal judgments was respect for the patient's autonomy as an expression of their human rights. Through critical analysis, this paper explores other bioethical considerations and the potential harms if they are ignored. Arguably, disclosure of DNACPR status on its own will do little to improve patient experience. A focus on good communication with those identified as approaching end-of-life will facilitate personalized care. Discussions around DNACPR may still occur, but only if likely to be beneficial and at a patient-appropriate pace (not dictated by the need to activate the decision).

Nurses' experience with relatives of patients receiving end-of-life care in nursing homes and at home: A questionnaire-based cross-sectional study

AIM

The aim of this study was to explore any differences between nurses working in nursing home and home-based care in their experiences regarding relatives' ability to accept the imminence of death and relatives' ability to reach agreement when deciding on behalf of patients unable to consent.

DESIGN

An electronic questionnaire-based cross-sectional study.

METHOD

An electronically distributed survey to 884 nurses in long-term care in Norway in May 2014. A total of 399 nurses responded (45%), of which 197 worked in nursing homes and 202 in home-based care.

RESULTS

Nurses in home-based care, more often than their colleagues in nursing homes, experienced that relatives had difficulties in accepting that patients were dying. Nurses who often felt insecure about whether life extension was in consistency with patients' wishes and nurses who talked most about life-prolonging medical treatment in communication with relatives more often experienced that relatives being reluctant to accept a poor prognosis and disagreements between relatives in their role as proxy decision makers for the patient.

Advance Care Planning in Norwegian nursing homes-Who is it for?

Advance care planning (ACP) is an international concept for improving patient autonomy and communication in the context of anticipated deterioration and end-of-life care. In a preparatory conversation, health care professionals facilitate one or more conversations where nursing home residents are invited to reflect on, and articulate wishes and preferences concerning future medical treatment and end-of-life care. Our aim with this study was to increase knowledge of existing ACP practices in Norwegian nursing homes. We wanted to know how nursing home residents, relatives and nursing home staff take part in the conversations, and to what extent these conversations can be regarded as promoting autonomy, legal rights and individual needs for the residents. We conducted participant observation of seven preparatory conversations, followed by interviews with health care staff (together) and resident and relative (together). In the result section, we present an informative case example of an ACP conversation where common and important characteristics running through our data are present. These are further elaborated under the following headings: Life critical questions, Residents' quiet participation in the conversations, the Dying phase - a clinical issue, Nurses and physicians; different domains and Timing. We find that nursing home staff in our study wants to contribute to open awareness, autonomy and a good death, but there are little reflections about the purpose and content of the conversations, how they should be carried out and when, and what frail nursing home residents are able to understand and express in ACP conversations.

The nature of, and reasons for, 'inappropriate' hospitalisations among patients with palliative care needs: a qualitative exploration of the views of generalist palliative care providers

BACKGROUND

Recent studies have concluded that there is significant potential to reduce the extent of 'inappropriate' hospitalisations among patients with palliative care needs. However, the nature of, and reasons for, inappropriate hospitalisations within a palliative care context is under-explored.

AIM

To explore the opinions of 'generalist' palliative care providers regarding the nature of, and reasons for, inappropriate admissions among hospital inpatients with palliative care needs.

DESIGN

Qualitative study with data collected via individual interviews and focus groups.

SETTING/PARTICIPANTS

Participants (n = 41) comprised 'generalist' palliative care providers working in acute hospital and community settings.

SETTING

One District Health Board in an urban area of New Zealand.

RESULTS

The majority of participants discussed 'appropriateness' in relation to their own understanding of a good death, which typically involved care being delivered in a 'homely' environment, from known people. Differing attitudes among cultural groups were also evident. The following reasons for inappropriate admissions were identified: family carers being unable to cope, the 'rescue culture' of modern medicine, the financing and availability of community services and practice within aged residential care.

CONCLUSIONS

On the basis of our findings, we recommend a shift to the term 'potentially avoidable' admission rather than 'inappropriate admission'. We also identify an urgent need for debate regarding the role of the acute hospital within a palliative care context. Interventions to reduce hospital admissions within this population must target societal understandings of death and dying within the context of medicalisation, as well as take into account cultural and ethnic diversity in attitudes, if they are to be successful.