Processes of adjustment to end-of-life losses: a reintegration model

Translation, Validity and Internal Consistency of the Quality of Dying and Death Questionnaire for Brazilian families of patients that died from cancer: a cross-sectional and methodological study

BACKGROUND

The Quality of Dying and Death Questionnaire (QoDD) may prove to be an important evaluation tool in the Brazilian context, and, therefore, can contribute to a more precise evaluation of the dying and death process, improving and guiding the end-of-life patient care.

OBJECTIVE

To translate and cross-culturally adapt the QoDD into Brazilian Portuguese and measure its validity (convergent and known-groups) and internal consistency.

DESIGN AND SETTING

A cross-sectional, methodological study was conducted at the Hospital de Câncer de Barretos, Brazil.

METHODS

A total of 78 family caregivers participated in this study. Semantic, cultural, and conceptual equivalences were evaluated using the content validity index. The construct validity was assessed through convergent validation and known groups analysis [presence of family members at the place of death; feel at peace with dying; and place of death (hospital versus home; hospital versus Palliative Care)]. Internal consistency was evaluated using Cronbach's alpha.

RESULTS

The questionnaire was translated into Brazilian Portuguese and presented evidence of a clear understanding of its content. Cronbach's alpha values were ≥ 0.70, except for the domains of treatment preference (α = 0.686) and general concerns (α = 0.599). The convergent validity confirmed a part of the previously hypothesized correlations between the Palliative Care Outcome Scale-Brazil (POS-Br) total scores and the QoDD domain scores. The QoDD-Br domains could distinguish the patients who died in palliative care and general wards.

CONCLUSION

The QoDD-Br is a culturally adapted valid instrument, and may be used to assess the quality of death of cancer patients.

Toward a clinical model for patient spiritual journeys in supportive and palliative care: Testing a concept of human spirituality and associated recursive states

OBJECTIVE

In 2015, a Chaplaincy Research Consortium generated a model of human spirituality in the palliative care context to further chaplaincy research. This article investigates the clinical fit of (a) the model's fundamental premise of universal human spirituality and (b) its 4 proposed stage descriptors (Discovery, Dialogue, Struggle, and Arrival).

METHOD

First, we collected qualitative data from an interdisciplinary palliative care focus group. Participants (n = 5) shared responses to the statement "the human spirit has essential commonalities across [ … ] groups and [ … ] attributes." Participants also shared vignettes of spiritual care, and 48 vignettes illustrating patients' spiritual journeys were subsequently taken from the transcript of that group. Second, we invited different mixed discipline palliative care professionals (n = 9) to individually card sort these vignettes to the model's 4 stage descriptors; we conducted pattern analysis on the results. We then administered a third step, convening six physicians to complete the card sort again, this time allowing designation of cards to one or two of the 4 stage descriptors.

RESULTS

Focus group participants were supportive of the model's all-encompassing definition of spirituality. The concept of "connectedness" was a shared focus for all participants, connectedness and spirituality appearing almost synonymous. Pattern analysis of assigned 48 vignettes to the 4 stages showed stronger consensus around Discovery and Arrival than Struggle and Dialogue. Results of the additional card sort suggested Struggle and Dialogue involve oscillation and are harder to think of as a steady state as distinct from processes associated with Discovery or Arrival.

SIGNIFICANCE OF RESULTS

"Connectedness" is a productive concept for modeling human spiritual experience near the end of life. As one healthcare professional said: "this connectedness piece is [ … ] what I always look for … " Although further work is needed to understand struggle and dialogue elements in peoples' spiritual journeys, discovery and arrival shared consensus among participants.

Dyadic Model of Adaptation to Life-Limiting Illness

Context: We previously developed the reintegration model to describe the adjustment process for individuals at the end of life. However, caregivers and loved ones also require significant support and must work to reimagine their relationship with one another. Objectives: We sought to develop a dyadic version of the reintegration model that delineates key parts of the adjustment process that occur between the patient and another significant person rather than as two separate individuals. Methods: We refined an initial conceptual model of this dyadic process with findings from a narrative literature review on spousal dyadic mutuality. We assessed emergent themes regarding dyadic adjustment from the literature for their fit with our original reintegration model and through consensus discussion, applied the findings to a final proposed conceptual model of dyadic reintegration at the end of life. Results: Examples of dyadic adjustment in the literature relate to the comprehension, creative adaptation, and reintegration processes described in the original reintegration model. Evidence also supported three substantive additions in the new dyadic model: (1) shared understanding that the harmony of the dyad is interrupted; (2) consideration of the "we" (the dyad) and the "I" (the individual) in mutual reflection to create a shared narrative; and (3) emphasis on relationship as a factor impacting adjustment processes. Conclusions: Available evidence supports interdependent relationships between members of dyads for the three adaptation processes of comprehension, creative adaptation, and reintegration in the model. This dyadic reintegration model can be useful in clinical practice to support dyads facing life-limiting illness.

The Chronic Sick Role: Its Time Has Come

The concept of roles has been crucial to the theoretical understanding of the construction of the dying process and the subjective experience of dying. Talcott Parsons first outlined the sick role in 1951. Beginning in the early 1960s, the academic literature recognized that those with chronic illness do not fit the criteria for the sick role as Parsons defined it. Since the introduction of hospice and palliative care, a new intermediate role has been constructed by the medical system. This role has been designated the chronic sick role. Formally defining the intermediate role between the sick and dying roles will help alleviate the issue of role confusion and serves to define what is now a gray and liminal phase between sickness and dying.

Introducing a model for emotional distress in respiratory disease: A systematic review and synthesis of symptom management models

AIM

To undertake a theoretical systematic review to develop a conceptual model of illness-related emotional distress in the context of symptom management in chronic respiratory disease.

DESIGN

We performed a systematic search to identify conceptual models.

DATA SOURCES

Electronic databases MEDLINE, CINAHL, EMBASE and PsycINFO were searched and papers included from inception of the search term until June 2017.

REVIEW METHODS

The review was conducted following Pound and Campbell's and Turner's theory synthesis. Conceptual models were appraised using Kaplan's criteria. Models were excluded if they referred to a specific condition and/or lacked clarity.

RESULTS

This synthesis, which includes five models and additional evidence, yielded a new conceptual model describing the processes of regulation and symptom self-management in chronic respiratory disease. Identified sources of illness-related emotional distress are new or increased symptoms, additional treatment, new restrictions in performance of daily life roles and increased unpredictability. People goals and self-efficacy were identified as further drivers of symptom self-management. The regulation process is embedded in contextual factors.

CONCLUSION

Theory synthesis provided transparent guidance in developing a model to understand of the factors driving self-management decisions. Therefore, the model has the potential to guide development of interventions that support symptom self-management in chronic respiratory disease.

IMPACT

This newly presented conceptual model of illness-related emotional distress provides an understanding of the factors that drive self-management decisions when peoples experience new or increased symptoms. Such understanding is critical for nursing practice to developing appropriate interventions, especially in support of people decision-making.

Finding a 'new normal' following acute illness: A qualitative study of influences on frail older people's care preferences

Background:

The frail older population is growing, and many frail older people have episodes of acute illness. Patient preferences are increasingly considered important in the delivery of person-centred care and may change following acute illness.

Aim:

To explore influences on the care preferences of frail older people with recent acute illness.

Design:

Qualitative in-depth individual interviews, with thematic analysis.

Setting/participants:

Maximum variation sample of 18 patients and 7 nominated family carers from a prospective cohort study of people aged over 65, scoring ⩾5 on the Clinical Frailty Scale, and with recent acute illness, who were not receiving specialist palliative care. Median patient age was 84 (inter-quartile range 81–87), 53% female. Median frailty score 6 (inter-quartile range 5–7).

Results:

Key influences on preferences were illness and care context, particularly hospital care; adaptation to changing health; achieving normality and social context. Participants focused on the outcomes of their care; hence, whether care was likely to help them ‘get back to normal’, or alternatively ‘find a new normal’ influenced preferences. For some, acute illness inhibited preference formation. Participants’ social context and the people available to provide support influenced place of care preferences. We combined these findings to model influences on preferences.

Conclusion:

‘Getting back to normal’ or ‘finding a new normal’ are key focuses for frail older people when considering their preferences. Following acute illness, clinicians should discuss preferences and care planning in terms of an achievable normal, and carefully consider the social context. Longitudinal research is needed to explore the influences on preferences over time.

The National Institutes of Health measure of Healing Experience of All Life Stressors (NIH-HEALS): Factor analysis and validation

Two hundred patients with severe and/or life-threatening disease were recruited form the NIH Clinical Center and participated in the validation of the NIH-HEALS, which included exploratory factor analysis, principal component analysis, reliability, convergent validity, and divergent validity analyses. Item-reducing principal components analysis and internal consistency and split-half reliability demonstrated excellent internal consistency and split-half reliability (Cronbach's alpha = 0.89, split-half reliability = 0.95). Exploratory factor analysis revealed a three-factor structure, namely Connection (including religious, spiritual, and interpersonal), Reflection & Introspection, and Trust & Acceptance. Seven items were not retained. Convergent and divergent validity of 35-item NIH-HEALS against other validated measures of healing and spirituality provided strong evidence for its validity. As predicted, the Healed factor of the Self-Integration Scale (SIS), and Meaning, Peace, and Faith factors of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being-12 Scale (FACIT-SP12) were all positively and significantly correlated with the NIH-HEALS and its three factors. Divergent validity was also confirmed by the significant negative correlation between the NIH-HEALS and the Codependent factor on the SIS. Confirmatory Factor Analyses revealed good model fit by GFI (0.96), adjusted GFI (0.95), SRMR (0.077), and RMSEA (0.065), supporting the use of the NIH-HEALS with 35 items.

Adjusting to a Diagnosis of Cancer: Processes for Building Patient Capacity for Decision-Making

This short report contributes to the expanding body of qualitative research literature about the cognitive processes of newly diagnosed cancer patients as they adjust to a diagnosis of cancer. The study is based on secondary qualitative analysis of audio records collected as part of a larger NIH study (RO1D: An Interdisciplinary Perspective: A Social Science Examination of Oncofertility RL1 HD058296). Core categories illustrate the processes of "naming it," "dealing with dealing with it," and finding the "new norm" and were based on nine patient experiences. We observe that our substantive conceptual categories have equivalents in bereavement and grief literature where researchers have posited the theory that processing the diagnosis of a terminal illness is the equivalent to adjusting to a bereavement. These findings emphasize the importance of understanding real-time patient thoughts and feelings as soon after diagnosis as was possible with full patient consent.

"And Yet It Was a Blessing": The Case for Existential Maturity

We are interested in the kind of well-being that can occur as a person approaches death; we call it “existential maturity.” We describe a conceptual model of this state that we felt was realized in an individual case, illustrating the state by describing the case. Our goal is to articulate a generalizable, working model of existential maturity in concepts and terms taken from fundamentals of psychodynamic theory. We hope that a recognizable case and a model-based way of thinking about what was going on can both help guide care that fosters existential maturity and stimulate more theoretical modeling of the state.

Advance care planning as a shared endeavor: completion of ACP documents in a multidisciplinary cancer program

OBJECTIVE

We examined the roles of oncology providers in advance care planning (ACP) delivery in the context of a multidisciplinary cancer program.

METHODS

Semi-structured interviews were conducted with 200 women with recurrent and/or metastatic breast or gynecologic cancer. Participants were asked to name providers they deemed important in their cancer care and whether they had discussed and/or completed ACP documentation. Evidence of ACP documentation was obtained from chart reviews.

RESULTS

Fifty percent of participants self-reported completing an advance directive (AD) and 48.5% had named a healthcare power of attorney (HPA), 38.5% had completed both, and 39.0% had completed neither document. Among women who self-reported completion of the documents, only 24.0% and 14.4% of women respectively had documentation of an AD and HPA in their chart. Completion of an AD was associated with number (adjusted odds ratio [AOR] = 1.49) and percentage (AOR = 6.58) of providers with whom the participant had a conversation about end-of-life decisions. Participants who named a social worker or nurse practitioner were more likely to report having completed an AD. Participants who named at least one provider in common (e.g., named the same oncologist) were more likely to have comparable behaviors related to naming a HPA (AOR = 1.13, p = 0.011) and completion of an AD (AOR = 1.06, p = 0.114).

CONCLUSIONS

Despite the important role of physicians in facilitating ACP discussions, involvement of other staff was associated with a greater likelihood of completion of ACP documentation. Patients may benefit from opportunities to discuss ACP with multiple members of their cancer care team. Copyright © 2015 John Wiley & Sons, Ltd.

Threading the cloak: palliative care education for care providers of adolescents and young adults with cancer

Medical providers are trained to investigate, diagnose, and treat cancer. Their primary goal is to maximize the chances of curing the patient, with less training provided on palliative care concepts and the unique developmental needs inherent in this population. Early, systematic integration of palliative care into standard oncology practice represents a valuable, imperative approach to improving the overall cancer experience for adolescents and young adults (AYAs). The importance of competent, confident, and compassionate providers for AYAs warrants the development of effective educational strategies for teaching AYA palliative care. Just as palliative care should be integrated early in the disease trajectory of AYA patients, palliative care training should be integrated early in professional development of trainees. As the AYA age spectrum represents sequential transitions through developmental stages, trainees experience changes in their learning needs during their progression through sequential phases of training. This article reviews unique epidemiologic, developmental, and psychosocial factors that make the provision of palliative care especially challenging in AYAs. A conceptual framework is provided for AYA palliative care education. Critical instructional strategies including experiential learning, group didactic opportunity, shared learning among care disciplines, bereaved family members as educators, and online learning are reviewed. Educational issues for provider training are addressed from the perspective of the trainer, trainee, and AYA. Goals and objectives for an AYA palliative care cancer rotation are presented. Guidance is also provided on ways to support an AYA's quality of life as end of life nears.

Intervention thresholds: a conceptual frame for advance care planning choices

Background

Advance care planning (ACP) provides for decisions in the event of decisional incapacity. Determining ahead of time what a person may want is challenging and limits the utility of ACP. We present empirical evidence for a new approach to ACP: the individual’s “intervention threshold.” The intervention threshold is intuitively understood by clinicians and lay people, but has not been thoroughly described, measured, or analyzed.

Methods

Using a mixed-methods approach to address the concept of the intervention thresholds, we recruited 52 subjects from a population of chronically ill outpatients for structured telephone interviews assessing knowledge, attitudes, and prior ACP activities. Respondents were presented with 11 interventions for each of four medical scenarios. For each scenario, they were asked whether they would accept each intervention. Data was evaluated by descriptive statistics and chi-squared statistics.

Results

Complete data were obtained from 52 patients, mean age of 64.5, 34.6% of whom were male. Only 17.3% reported prior ACP discussion with a physician. Rates of accepting and refusing interventions varied by scenario (p < 0.0001) and intervention intensity (p < 0.0001).

Conclusions

These data provide evidence that people display transitions between wanting or not wanting interventions based on scenarios. Further research is needed to determine effective ways to identify, measure, and represent the components of an individual’s intervention threshold in order to facilitate informed decision making during future incapacity.

Life Closure with the Roy Adaptation Model

The author of this paper examines the initial conceptualization of death and dying theory within the context of the Roy adaptation model (RAM) and compares it with current knowledge development. An evolved RAM with its philosophic assumptions provides a framework by which to add existential components of spirituality, life meaning, and purposeful existence that were absent in the original work on death and dying.

Exerting control and adapting to loss in amyotrophic lateral sclerosis

People with amyotrophic lateral sclerosis (ALS) engage with a broad range of health care services from symptom onset to end-of-life care. We undertook a grounded theory study to identify processes that underpin how and why people with ALS engage with health care services. Using theoretical sampling procedures, we sampled 34 people from the Irish ALS population-based register during September 2011 to August 2012. We conducted in-depth interviews with participants about their experiences of health care services. Our study yielded new insights into how people with ALS engage with services and adapt to loss. People with ALS live with insurmountable loss and never regain what they have already lost. Loss for people with ALS is multidimensional and includes loss of control. The experience of loss of control prompts people with ALS to search for control over health care services but exerting control in health care services can also include rendering control to service providers. People with ALS negotiate loss by exerting control over and rendering control to health care services. Our findings are important for future research that is attuned to how people with terminal illness exert control in health care services and make decisions about care in the context of mounting loss.

Final decisions: how hospice enrollment prompts meaningful choices about life closure

OBJECTIVE

The purpose of this study was to explore and describe decisions that faced newly enrolled hospice patients and their caregivers after hospice enrollment.

METHOD

An exploratory, descriptive, cross-sectional design was employed using qualitative methods. In-depth in-person interviews were conducted with current hospice patients (n = 35) and caregivers (n = 45) from 53 families.

RESULTS

The decision to enroll in hospice was a critical juncture on the trajectory of a terminal illness that allowed patients and their families an opportunity to consider subsequent tasks that were important for life closure. A typology of five decisions is presented: (1) operationalized advance care planning (ACP): a renewed focus on decisions about care at life's end; (2) surrogate decision-making: caregivers begin making both informal and formal decisions for the dying person; (3) meaning-making: the foreshortened time brings into focus decisions about seeing special people, attending events, and creating memories; (4) Location of death: decisions about whether the person wants to and can remain at home to die; and (5) final acts: decisions about funeral arrangements, wills, and leaving a legacy become central. ACP was found to exist on a continuum that ranged from absent ACP, dormant ACP, simplified ACP to activated ACP. Hospice enrollment became a catalyst for reactivating discussion of end-of-life choices.

SIGNIFICANCE OF RESULTS

Hospice enrollment prompts the need to consider subsequent important choices that contribute to meaningful life closure, are central to the completion of a family relationship, and may influence adaptation in bereaved caregivers. It is important for clinicians to recognize that well-timed encouragement to consider and explore the use of hospice services, although it may indeed diminish hope for cure or recovery, simultaneously offers an opportunity to engage with important and time-sensitive developmental tasks.

Perceptions of two therapeutic approaches for palliative care patients experiencing death anxiety

Objective:

Evidenced-based psychotherapies are not well researched for palliative care patients experiencing unrelenting anxiety about dying, even less research is focused on young adult palliative care patients with death anxiety. The aim of this study is to provide preliminary data regarding potential clients' perceptions of using evidenced based treatments with dying populations who are experiencing death anxiety.

Methods:

104 college students were used as potential clients and randomly assigned to watch either a short video of a cognitive therapy (CT) session or of an acceptance and commitment therapy (ACT) session focused on treating a young adult diagnosed with an acute lymphoid leukemia expressing death anxiety. After watching the video, potential clients rated the session impact of the therapy approach using the Session Evaluation Questionnaire.

Results:

No differences in ratings of session impact were found between potential clients who viewed the CT session and the ACT session. In regards to potential clients' views of session impact variables, their view of session smoothness was positively related to their post-session positivity, but inversely related to their view of session depth. Additionally, a positive correlation was found between potential clients' views of the therapist and session depth.

Significance of results:

This preliminary study suggests that palliative care patients expressing death anxiety may benefit from either ACT or CT for death anxiety, however, future research is needed to explore the usefulness of each approach. Findings of this study support the theory that ACT and CT are viewed to have a similar session impact in the palliative care population.

Path toward economic resilience for family caregivers: mitigating household deprivation and the health care talent shortage at the same time

Rising costs and a workforce talent shortage are two of the health care industry's most pressing challenges. In particular, serious illnesses often impose significant costs on individuals and their families, which can place families at an increased risk for multigenerational economic deprivation or even an illness-poverty trap. At the same time, family caregivers often acquire a wide variety of health care skills that neither these caregivers nor the health care industry typically use. As these skills are marketable and could be paired with many existing medical certifications, this article describes a possible "path toward economic resilience" (PER) through a program whereby family caregivers could find meaningful employment using their new skills. The proposed program would identify ideal program candidates, assess and supplement their competencies, and connect them to the health care industry. We provide a set of practical steps and recommended tools for implementation, discuss pilot data on the program's appeal and feasibility, and raise several considerations for program development and future research. Our analysis suggests that this PER program could appeal to family caregivers and the health care industry alike, possibly helping to address two of our health care system's most pressing challenges with one solution.

Know your patient: psychological drivers of decision making

This is a commentary on “Attitudes of legal guardians of ventilated ICU patients toward the process of decision making associated with invasive nonlife-saving procedures” by Michael Kuniavsky, Freda DeKeyser Ganz, David M Linton, and Sigal Sviri. Kuniavsky and colleagues report that decision-making for the seriously ill is difficult for the patients’ legal guardians, many of whom would be comfortable with doctors making the decisions. This commentary offers that accurate predictions about treatment choices may be derived by using assessments that characterize the key drivers of individual’s decision making, thus relieving some of decision makers' burdens. This approach could also usher in an era of assessing quality of care for the seriously ill by whether the care matches patient goals.

The influence of time and adaptation on health state valuations in patients with spinal cord injury

OBJECTIVES

One of the explanations for the difference between health state utilities elicited from patients and the public--often provided but seldom studied--is adaptation. The influence of adaptation on utilities was investigated in patients with spinal cord injury.

METHODS

Interviews were held at 3 time points (T1, after admission to the rehabilitation center; T2, during active rehabilitation; T3, at least half a year after discharge). At T1, 60 patients were interviewed; 10 patients withdrew at T2 and T3. At all time points, patients were asked to value their own health and a health state description of rheumatoid arthritis on a time trade-off and a visual analogue scale. The Barthel Index, a measure of independence from help in activities of daily living, and the adjustment ladder were filled out. Main analyses were performed using mixed linear models taking the time-dependent covariates (Barthel Index and adjustment ladder) into account.

RESULTS

Time trade-off valuations for patients' own health changed over time, even after correction for gain in independence from help in activities of daily living, F(2, 59) = 8.86, P < 0.001. This change was related to overall adaptation. Both a main effect for adaptation, F(87, 1) = 10.05; P = 0.002, and an interaction effect between adaptation and time, F(41, 1)= 4.10, P = 0.024, were seen for time trade-off valuations. Valuations given for one's own health on the visual analogue scale did not significantly change over time, nor did the valuations for the hypothetical health state.

CONCLUSION

Patients' health state valuations change over time, over and above the change expected by the rehabilitation process, and this change is partly explained by adaptation. Experience with a chronic illness did not lead to change in valuations of hypothetical health states.

The salience of existential concerns across the cancer control continuum

Despite significant improvement in cancer survival, the fear of death still remains rooted in individuals' beliefs about cancer. Existential fears pertaining to cancer cut across the cancer control continuum and taint decisions related to prevention, screening, surveillance, and follow-up recommendations, as well as the overall management of cancer-related issues. However, individuals are innately predisposed to cope with their cancer-related fears through mechanisms such as reliance on the process of meaning making. To better appreciate the potential impact of existential concerns across the cancer control continuum, the Temporal Existential Awareness and Meaning Making (TEAMM) model is proposed. This tripartite model depicts three types of perceived threats to life related to cancer including a “social awareness” (i.e., cancer signals death), “personalized awareness” (i.e., I could die from cancer), and the “lived experience” (i.e., It feels like I am dying from cancer). This construal aims to enhance our understanding of the personal and contextual resources that can be mobilized to manage existential concerns and optimize cancer control efforts. As such, existential discussions should be considered in any cancer-related supportive approach whether preventive, curative, or palliative, and not be deferred only until the advanced stages of cancer or at end of life. Further delineation and validation of the model is needed to explicitly recognize and depict how different levels of existential awareness might unfold as individuals grapple with a potential, actual, or recurrent cancer.

The experience of living at home with frailty in old age: a psychosocial qualitative study

BACKGROUND

With enhanced longevity, many people in late old age find themselves frail and living at home, often alone. Whilst conceptualisations vary, frailty is often used in clinical practice as a directional term, to refer to older people at particular risk of adverse health outcomes and to organise care. Investigation of the experience of being frail is a complementary and necessary addition to international research endeavours clearly to define, predict and measure frailty. Currently, there is little empirical work exploring how people over time manage being frail.

OBJECTIVE

The study aimed to understand the experience over time of home-dwelling older people deemed frail, in order to enhance the evidence base for person-centred approaches to frail elder care.

DESIGN

The study design combined psychosocial narrative approaches and psycho-dynamically informed observation. Data on the experience of 15 frail older people were collected by visiting them up to four times over 17 months. These data were analyzed using psychosocial analytical methods that combined case based in-depth staged analysis of narratives with psycho-dynamically informed interpretations of observational data.

SETTING

The study was carried out in the homes of the participants; all lived in a socio-economically diverse area of inner London.

PARTICIPANTS

15 participants were purposively selected for living at home, being aged 85 or older and regarded as frail by a clinical multi-disciplinary intermediate care team.

RESULTS

The findings challenge the negative terms in which frailty in older age is viewed in the predominant models. Rather, frailty is understood in terms of potential capacity - a state of imbalance in which people experience accumulated losses whilst working to sustain and perhaps create new connections.

CONCLUSION

This study suggests that holding together loss and creativity is the ordinary, but nonetheless remarkable, experience of frail older people. For frail older people, the presence of others to engage with their stories, to recognise and value the daily rituals that anchor their experience and to facilitate creative connections is vital if they are to retain capacity and quality of life whilst being frail.

Toward development of a middle-range theory of psychological adaptation in death and dying

This paper presents a middle-range theory of psychological adaptation in death and dying that was abstracted from a series of quantitative and qualitative studies. The findings from these studies are described, a conceptual definition for end-of-life psychological adaptation is given, evidence is synthesized into a limited number of assumptions, testable hypotheses are derived, and the constructed middle-range theory is linked to the conceptual-theoretical framework of the Roy adaptation model.

Palliative medicine and decision science: the critical need for a shared agenda to foster informed patient choice in serious illness

Assisting patients and their families in complex decision making is a foundational skill in palliative care; however, palliative care clinicians and scientists have just begun to establish an evidence base for best practice in assisting patients and families in complex decision making. Decision scientists aim to understand and clarify the concepts and techniques of shared decision making (SDM), decision support, and informed patient choice in order to ensure that patient and family perspectives shape their health care experience. Patients with serious illness and their families are faced with myriad complex decisions over the course of illness and as death approaches. If patients lose capacity, then surrogate decision makers are cast into the decision-making role. The fields of palliative care and decision science have grown in parallel. There is much to be gained in advancing the practices of complex decision making in serious illness through increased collaboration. The purpose of this article is to use a case study to highlight the broad range of difficult decisions, issues, and opportunities imposed by a life-limiting illness in order to illustrate how collaboration and a joint research agenda between palliative care and decision science researchers, theorists, and clinicians might guide best practices for patients and their families.

Can a good death and quality of life be achieved for patients with terminal cancer in a palliative care unit?

BACKGROUND

Lack of evidence supporting the claim that palliative care can improve quality of life and promote good death in patients with terminal cancer.

OBJECTIVES

This study was designed to evaluate the change of quality of life and quality of death over time and between patients of long and short survival in a palliative care unit.

METHODS

Patient demography, cancer sites, Eastern Cooperative Oncology Group (ECOG) status were collected at admission. Quality of life, including physical and psychological symptoms, social support, and spirituality was assessed daily after admission. Quality of death was assessed by a Good Death Scale (GDS) at admission and retrospectively for 2 days before death.

RESULTS

A total of 281 patients (52% women) were admitted and died in the study period. One hundred forty-five patients (51.6%) died within 3 weeks. Although those with short survival (<3 weeks) had more physical symptoms during the first week, there was no difference in quality of life dimensions at admission, at 1 week, and at 2 days before death between survival groups. Physical conditions deteriorated with time but other dimensions continued to improve until death. GDS and subdimensions continued to improve until death. Although those with long survival (≥3 weeks) have better scores for awareness, acceptance, timeliness, comfort, and GDS at admission, there was no difference between the two groups at 2 days before death.

CONCLUSION

Under comprehensive palliative care, patients with terminal cancer can have good quality of life and experience a good death even with short survival.

Redefining the "planning" in advance care planning: preparing for end-of-life decision making

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

Redefining the "planning" in advance care planning: preparing for end-of-life decision making

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives

We used exploratory factor analysis within the confirmatory analysis framework, and data provided by family members and friends of 205 decedents in Missoula, Montana, to construct a model of latent-variable domains underlying the Quality of Dying and Death questionnaire (QODD). We then used data from 182 surrogate respondents, who were survivors of Seattle decedents, to verify the latent-variable structure. Results from the two samples suggested that survivors' retrospective ratings of 13 specific aspects of decedents' end-of-life experience served as indicators of four correlated, but distinct, latent-variable domains: Symptom Control, Preparation, Connectedness, and Transcendence. A model testing a unidimensional domain structure exhibited unsatisfactory fit to the data, implying that a single global quality measure of dying and death may provide insufficient evidence for guiding clinical practice, evaluating interventions to improve quality of care or assessing the status or trajectory of individual patients. In anticipation of possible future research tying the quality of dying and death to theoretical constructs, we linked the inferred domains to concepts from identity theory and existential psychology. We conclude that research based on the current version of the QODD might benefit from the use of composite measures representing the four identified domains, but that future expansion and modification of the questionnaire are in order.

Providing inbuilt economic resilience options : an obligation of comprehensive cancer care

For many, a cancer death in the family is the immediately obvious part of what is actually a double devastation. Overwhelming financial damage also results for many families, from the cost of medical care and from the loss of earning power by the patient and family. For some families, the consequences may be multigenerational and can affect the health of the survivors. Although this situation is not limited to cancer, the authors argue that oncology can take a lead in attending to these consequences of cancer as an integral part of its commitment to comprehensive cancer care. They make this case for both the national and the international settings. They also articulate and illustrate the notion of inbuilt options for economic resilience (IERs), which the authors suggest the medical industry, and its cancer care sectors in particular, should be providing to all patients and their families if they are at risk for damaging financial losses. After describing key features to IER, the authors illustrate it with 1 type of approach for households of the terminally ill: hospice care with provision of supplementary training and certification to the family caregiver. Such programming could generate a low-technology, semiskilled healthcare service economy as trained family caregivers provide support to other households in need, thereby both providing a recovery option for themselves and reduced economic devastation to the households which, by receiving the services, can stay in the workforce. Finally, the authors call for invigorated research on the economic impact of cancer on families and for the modeling, demonstration, and study of options for economic resilience, including IER programs.

Advance directives

Most patients want some control over their medical care, including-or even especially-when they are too sick to participate in decisions. Clinicians who have to make decisions for patients who are unable to participate often would appreciate guidance from patients' wishes. Advance care planning responds to these needs. The process provides for discussions about goals in different scenarios and allows inclusion of the family and physician as well as the patient. It helps to have the patient and family complete validated worksheets that walk them through the various considerations and result in expressions of preference that are clinically meaningful. For the clinician, scenario-based goals for care and personal thresholds for when desired care shifts from primarily cure-oriented to primarily palliative are the most useful features to know about. The patient and family should do most of the discussing on their own time; the physician and team should coordinate to screen for problems and ensure agreement. Ideally, this should occur over the course of regular clinical encounters, with some dedicated time for the topic at suitable intervals.