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Parsons C, Escobar C, Jasani A, Zhao D, Gliatto P, Blutinger E, Ornstein KA. Community paramedicine in dementia care. J Am Geriatr Soc 2024; 72:2167-2173. [PMID: 38485282 PMCID: PMC11226359 DOI: 10.1111/jgs.18872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/27/2024] [Accepted: 02/19/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Novel hospital diversion strategies are needed to support a growing number of patients with dementia living in the community. One promising model is community paramedicine (CP), which deploys paramedics to the home, who consult with a physician to coordinate treatment and assess disposition. While evidence suggests CP can manage many patients without escalation to the emergency department (ED), no studies have evaluated optimal CP utilization for patients with dementia. Therefore, we compare the use and outcomes of CP for homebound patients with and without dementia. METHODS This retrospective cohort study examines 251 homebound patients receiving home-based primary care, who utilized a physician-led CP service between March 2017 and May 2022. Linked electronic health record data included patient demographics, clinical characteristics, and CP encounter details. Dementia status and CP outcomes, including rates of ED transport, over-transport (i.e., transported, but not hospitalized), and under-transport (i.e., not transported, but ED visit within 3 days), were determined via chart review. Using logistic regression, we modeled the association of dementia status with over- and under-transport, adjusting for age, sex, and chief complaint. RESULTS Fifty-three percent of CP patients had dementia. Their most common chief complaints were dyspnea (24.3%), altered mental status (17.9%), and generalized weakness (9.8%). We found no significant difference in ED transport rates by dementia status (25.4 vs. 22.8%, p = 0.54). Dementia diagnosis was associated with lower rates of over-transport (OR = 0.21, p = 0.03, CI [0.05, 0.85]) and comparable rates of under-transport (OR = 0.70, p = 0.47, CI [0.27, 1.83]) in adjusted models. CONCLUSIONS CP has effectively managed a diverse population of homebound patients with dementia cared for via home-based primary care. Future work should examine potential cost savings and use of CP in dementia care across geographic and healthcare settings.
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Affiliation(s)
- Colby Parsons
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Escobar
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy Jasani
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Duzhi Zhao
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Gliatto
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erik Blutinger
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, Johns Hopkins University, School of Nursing, Baltimore, Maryland, USA
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Owusuaa C, van Beelen I, van der Heide A, van der Rijt CCD. Physicians' views on the usefulness and feasibility of identifying and disclosing patients' last phase of life: a focus group study. BMJ Support Palliat Care 2021:bmjspcare-2020-002764. [PMID: 33619221 DOI: 10.1136/bmjspcare-2020-002764] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Accurate assessment that a patient is in the last phase of life is a prerequisite for timely initiation of palliative care in patients with a life-limiting disease, such as advanced cancer or advanced organ failure. Several palliative care quality standards recommend the surprise question (SQ) to identify those patients. Little is known about physicians' views on identifying and disclosing the last phase of life of patients with different illness trajectories. METHODS Data from two focus groups were analysed using thematic analysis with a phenomenological approach. RESULTS Fifteen medical specialists and general practitioners participated. Participants thought prediction of patients' last phase of life, i.e. expected death within 1 year, is important. They seemed to find that prediction is more difficult in patients with advanced organ failure compared with cancer. The SQ was considered a useful prognostic tool; its use is facilitated by its simplicity but hampered by its subjective character. The medical specialist was considered mainly responsible for prognosticating and gradually disclosing the last phase. Participants' reluctance to such disclosure was related to uncertainty around prognostication, concerns about depriving patients of hope, affecting the physician-patient relationship, or a lack of time or availability of palliative care services. CONCLUSIONS Physicians consider the assessment of patients' last phase of life important and support use of the SQ in patients with different illness trajectories. However, barriers in disclosing expected death are prognostic uncertainty, possible deprivation of hope, physician-patient relationship, and lack of time or palliative care services. Future studies should examine patients' preferences for those discussions.
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Affiliation(s)
- Catherine Owusuaa
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Irene van Beelen
- Medical Oncology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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Åvik Persson H, Sandgren A, Fürst CJ, Ahlström G, Behm L. Early and late signs that precede dying among older persons in nursing homes: the multidisciplinary team's perspective. BMC Geriatr 2018; 18:134. [PMID: 29898674 PMCID: PMC6000966 DOI: 10.1186/s12877-018-0825-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 05/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nursing home residents in Sweden are old, frail and usually have multiple morbidities which often make dying a prolonged suffering. It has been found that older persons at nursing homes receive far less palliative care than younger persons, partly because it is difficult to identify when the final stage of life begins. The identification may help the staff to enable the older person and their families to participate in planning the care in accordance with their own preferences and values. With this in mind the aim was to explore the experiences of early and late signs preceding dying in older persons in nursing homes from the multidisciplinary team's perspective. METHODS The focus group method was used to interview 20 health-care professionals on the basis of semi-structured questions. Four focus groups were conducted at four nursing homes in two counties in southern Sweden. The groups included different professionals such as assistant nurses, registered nurses, occupational therapists, physiotherapists, social workers and unit managers. The analysis was conducted according to the focus group method developed by Kruger and Casey. RESULTS The analysis revealed one major theme, from unawareness to obviousness, which illustrates that the participants experienced dying as a happening, not a process, and found it difficult to identify early signs. Even though it was a new way of thinking, several suggestions of early signs were presented. The main category "Going into a bubble" illustrates early signs, which meant that the older person showed signs of wanting to withdraw from the outside world. The main category "The body begins to shut down" illustrates late signs, which meant that the older person showed signs that indicate that the body starts to prepare for death. CONCLUSIONS This study conveys new knowledge concerning the multidisciplinary team's collective experience of early and late signs that precede dying. This knowledge can increase the understanding of when a palliative care approach needs to be in place at nursing homes. The use of a palliative care approach in care planning requires consensus in the perception of the dying process of frail older persons.
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Affiliation(s)
- Helene Åvik Persson
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, 221 00, Lund, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Carl-Johan Fürst
- The Institute for Palliative Care, Lund University and Region Skåne, 221 00, Lund, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, 221 00, Lund, Sweden
| | - Lina Behm
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, 221 00, Lund, Sweden
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Falk H, Henoch I, Ozanne A, Öhlen J, Ung EJ, Fridh I, Sarenmalm EK, Falk K. Differences in Symptom Distress Based on Gender and Palliative Care Designation Among Hospitalized Patients. J Nurs Scholarsh 2016; 48:569-576. [PMID: 27668982 DOI: 10.1111/jnu.12254] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE To explore patient-reported symptom distress in relation to documentation of symptoms and palliative care designation in hospital inpatients. DESIGN This cross-sectional study analyzed data from 710 inpatients at two large hospitals in Sweden using the Edmonton Symptom Assessment Scale and the Memorial Symptom Assessment Scale. Chart reviews focused on nurses' and physicians' symptom documentation and palliative turning point. METHODS Descriptive statistics were calculated for all variables and provided summaries about the sample. Patients were grouped according to gender, age, palliative care designation, and symptom documentation. The t test and chi-square test were used to calculate whether symptom distress varied between groups. A two-way analysis of variance was conducted for multiple comparisons to explore the impact of gender and age on mean symptom distress. FINDINGS Females reported higher levels of symptom distress than did males related to pain, fatigue, and nausea. When comparing symptom distress between males and females with documentation pertaining to symptoms, there were significant differences implying that females had to report higher levels of symptom distress than males in order to have their symptoms documented. CONCLUSIONS Females need to report higher levels of symptom distress than do males for healthcare professionals to identify and document their symptoms. It can be hypothesized that females are not receiving the same attention and symptom alleviation as men. If so, this highlights a serious inequality in care that requires further exploration. CLINICAL RELEVANCE Considering that common reasons why people seek health care are troublesome symptoms of illness, and that the clinical and demographic characteristics of inpatients are changing towards more advanced ages with serious illnesses, inadequate symptom assessment and management are a serious threat to the care quality.
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Affiliation(s)
- Hanna Falk
- Assistant Professor, The Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden. .,Assistant Professor, University of Gothenburg, Centre for Ageing and Health (AGECAP), Gothenburg, Sweden.
| | - Ingela Henoch
- Associate Professor, University of Gothenburg, Centre for Ageing and Health (AGECAP), Gothenburg, Sweden
| | - Anneli Ozanne
- Assistant Professor, The Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
| | - Joakim Öhlen
- Professor, The Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden.,Professor, Palliative Research Centre, Ersta Sköndal University College, Stockholm, Sweden.,Professor, University of Gothenburg, Centre for Person-Centred Care (GPCC), Gothenburg, Sweden
| | - Eva Jakobsson Ung
- Associate Professor, The Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
| | - Isabell Fridh
- Assistant Professor, Faculty of Caring Science, Work Life and Social Welfare University of Borås, Borås, Sweden
| | | | - Kristin Falk
- Associate Professor, University of Gothenburg, Centre for Ageing and Health (AGECAP), Gothenburg, Sweden.,Associate Professor, The Sahlgrenska Academy, University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
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Adorno G. Between Two Worlds: Liminality and Late-Stage Cancer-Directed Therapy. OMEGA-JOURNAL OF DEATH AND DYING 2015; 71:99-125. [PMID: 26625508 DOI: 10.1177/0030222815570589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Disease-directed therapy near death is a growing trend among persons living with late-stage cancer. As a sociocultural phenomenon, cancer-directed therapy (e.g., chemotherapy) when given for very advanced disease is a process that offers questionable benefits and portends further suffering, but also suggests potential for growth and transcendence. Theories and concepts drawn from cultural anthropology, sociology, and existentialism illustrate how contextual factors contribute to the creation of a "liminal space"; the latter part of the cancer trajectory where living and dying can overlap. When applied to clinical practice, this theoretical framework gives the patient, family, and health care provider a way of "unmasking" a period of transition during terminal illness when aggressive disease-directed care continues to be provided. The liminal space may function as an existential plane; a gateway or threshold with inherent potential for psychospiritual development during the final stage of life.
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Elliott M, Nicholson C. A qualitative study exploring use of the surprise question in the care of older people: perceptions of general practitioners and challenges for practice. BMJ Support Palliat Care 2014; 7:32-38. [DOI: 10.1136/bmjspcare-2014-000679] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/16/2014] [Accepted: 08/13/2014] [Indexed: 11/03/2022]
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West E, Romoli V, Di Leo S, Higginson IJ, Miccinesi G, Costantini M. Feasibility of assessing quality of care at the end of life in two cluster trials using an after-death approach with multiple assessments. BMC Palliat Care 2014; 13:36. [PMID: 25071416 PMCID: PMC4113121 DOI: 10.1186/1472-684x-13-36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 07/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2009 two randomised cluster trials took place to assess the introduction of the Italian Version of the Liverpool Care Pathway in hospitals and hospices. Before and after data were gathered. The primary aim of this study is to evaluate the feasibility of using a combination of assessment methods aimed at different proxy respondents to create a means of measuring quality of care at the end of life. We also aim to explore whether there are differences in response to this approach between the hospice and hospital inpatient settings. METHODS A retrospective design was used. Eligible deaths were traced through death registries, and proxies were used to give information. Four procedures of assessment were used to measure different dimensions. Feasibility was assessed through compliance and adherence to the study instruments, and measured against standards derived from previous after-death studies. The proxy caregiver's rating of the study tools was also measured, to gauge feasibility and effectiveness. All consecutive cancer deaths that occurred in the study period were eligible. In both trials, deaths were excluded if the patient was a relative of hospital/hospice staff. 145 patients were recruited from the Hospital setting, and 127 from Hospice. RESULTS A high proportion of non-professional caregivers were interviewed - in both hospital (76.6%) and hospice (74.8%). There was no significant difference in the median number of days in each setting. 89.0% of hospital patients' GPs and 85.0% of hospice patients' GPs were interviewed. Care procedures were recorded in all hospice cases, and were missing in only 1 hospital case.52.7% of Hospital patients' relatives and 64.12% Hospice relatives were assessed to have been caused a low level of distress through the study. CONCLUSIONS The data shows high levels of compliance and adherence to the study instruments. This suggests that this approach to assessing quality of care is feasible, and this coupled with low levels of distress caused by the study instruments suggest effectiveness. There were no substantial differences between the hospice and hospital settings.
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Affiliation(s)
- Emily West
- EMGO + Institute for Health and Care Research-Vrije Universiteit Medisch Centrum, Van der Boechorststraat 7, Amsterdam, 1081 BT, The Netherlands ; Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Vittoria Romoli
- Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Silvia Di Leo
- Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation-Cicely Saunders Institute, Kings College London, London, UK
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, ISPO Institute for the Study and Prevention of Cancer, Florence, Italy
| | - Massimo Costantini
- Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy ; Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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Affiliation(s)
- Joakim Öhlén
- Palliative Research Centre, Ersta Sköndal University College, Sweden; Institute of Health and Care Sciences, The Sahlgrenska Academy at the University of Gothenburg, Sweden; University of Gothenburg Centre for Person-Centred Care, Sweden
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Brännström M, Hägglund L, Fürst CJ, Boman K. Unequal care for dying patients in Sweden: a comparative registry study of deaths from heart disease and cancer. Eur J Cardiovasc Nurs 2012; 11:454-9. [PMID: 21764639 DOI: 10.1016/j.ejcnurse.2011.06.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The Swedish Palliative Registry is a nationwide quality registry aimed at facilitating improvement in end-of-life care. The goal is for the registry to list and report quality indicators related to care during the last week of life in all cases expected death in Sweden. AIM To examine the quality of care during the last week of life as reported to the registry for patients with heart disease compared to those with cancer. METHOD A retrospective registry study. RESULTS Patients dying of heart disease compared to those dying from cancer had more shortness of breath, fewer drugs prescribed as needed against the usual symptoms and often died alone. Furthermore, they and their close relatives received less information about the imminence of death and bereavement follow-up was less common. The healthcare personnel were less aware of the heart disease patients' symptoms and less often knew about where they wished to die. CONCLUSION Great differences were found in registered end-of-life care suggesting that the care given to patients with heart disease and cancer was unequal even after adjustment for age, sex and setting at the time of death. If our observational findings are confirmed in future studies there is obviously a need for new models for end-of-life management in order to facilitate the provision of equal care to dying patients regardless of diagnosis.
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Wallerstedt B, Sahlberg-Blom E, Benzein E, Andershed B. Identification and documentation of persons being in palliative phase regardless of age, diagnosis and places of care, and their use of a sitting service at the end of life. Scand J Caring Sci 2012; 26:561-8. [DOI: 10.1111/j.1471-6712.2011.00966.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Transition from curative efforts to purely palliative care for neonates: does physiology matter? Adv Neonatal Care 2011; 11:216-22. [PMID: 21730916 DOI: 10.1097/anc.0b013e31821be411] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To isolate the threshold point in which the goal of care for an infant with life-limiting conditions transitions from curative efforts to purely palliative care. DESIGN Descriptive Web-based survey of 285 neonatal physicians and nurses who had participated in care of dying infants. METHOD Researcher-developed tool measured multiple palliative care concepts related to transition to purely palliative care, such as identification of infants for whom purely palliative care should be offered; physician and nurse satisfaction with and barriers to the transition process; physiological factors that indicated that the infant was ready for transition to purely palliative care; publication knowledge to guide palliative care; and factors influencing decision making. RESULTS The study aim was to identify the physiology involved in coming to the end of life and indicating a transition need for palliative care. But although the respondents were able to identify physiological factors or lethal conditions leading to a transition to purely palliative care, they stated that these factors were not how the goals of care were established. Respondents (96%) stated that parental agreement was the determinant to palliative care transition, and, regardless of neonatal physiological condition, without agreement, curative technological efforts continued. Respondents felt that more education on the palliative care process for both staff and families was necessary to move dignified end-of-life care forward. CONCLUSIONS Parents must be our partners when the burden of care to the infant is greater than the benefit. Suggestions to assist both parents and providers are offered. CLINICAL RELEVANCE Although this study is based on end-of-life decision making for newborns, the findings may resonate to nurses who care for dying patients of any age group, with any diagnosis, cared for in any type of medical-surgical or critical care unit. The findings describe the American concept of patient and family autonomy and problems that have arisen from the implementation of autonomy in end-of-life decision making regarding withholding/withdrawing therapies that provide artificial life support.
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A discourse of silence: professional carers reasoning about death and dying in nursing homes. AGEING & SOCIETY 2011. [DOI: 10.1017/s0144686x10000905] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTNursing homes are a setting in which death and dying is common. How death and dying is articulated and the actions that take place in a nursing home constitute a discourse that guides the staff in their work. The aim of this study was to explore the discourse of death and dying in nursing homes from the perspective and understanding of the staff. The study draws on Foucault's discourse analysis. Data are from five focus-group discussions held with 28 staff of four different nursing homes in Sweden. The findings show that the discourse had three characteristics: (a) dying was silent and silenced, (b) emotions were pushed into the background, and (c) attentiveness to death arose after the moment of the elderly person's death. The structure of the discourse was characterised by a movement between two positions, avoiding and confronting death, the main focus being on avoidance. The articulation and practices of silence highlight a need to regard dying as a process that requires attention. One way to ensure appropriate attention could be to instil the philosophy of palliative care in nursing homes, including training and support for the staff in their work. The study demonstrates that nursing-home staff need more knowledge and support to enable them to feel that they do a good job.
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Pritchard M, Srivastava DK, Okuma JO, Powell B, Burghen E, West NK, Gattuso JS, Spunt SL, Baker JN, Kane J, Furman WL, Hinds PS. Bereaved parents' perceptions about when their child's cancer-related death would occur. J Pain Symptom Manage 2009; 38:561-7. [PMID: 19822277 PMCID: PMC2941143 DOI: 10.1016/j.jpainsymman.2009.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 01/14/2009] [Accepted: 02/19/2009] [Indexed: 11/17/2022]
Abstract
Parents of terminally ill children with cancer frequently ask clinicians when their child will die. Such information helps parents prepare for the child's death. To identify how parents perceived when their child's cancer-related death would occur, we conducted a secondary analysis of telephone interviews with 49 bereaved parents 6-10 months after their child's death to extract their descriptions of this occurrence. The parents knew in advance that their child was going to die, but they described when their child's death would occur in three different ways: anticipated (parents observed changes that alerted them that death was imminent; n=22, 52.4%), surprising (parents were surprised that their child died on that particular day; n=13, 31.0%), and overdue (parents had been waiting for the end of their child's apparent suffering; n=7, 16.7%). These categories did not differ by patients' diagnosis, sex, or location of death but differed slightly by symptom patterns. Parents who reported the occurrence of their child's death as surprising reported fewer symptom changes on the last day of their child's life, compared with the last week of life, than did the parents in the other two categories. These findings indicate that parents of children with terminal cancer can perceive when their child's death would occur very differently: Some are surprised, whereas others feel they have waited too long for their child's release from suffering. Clinicians can use these descriptions and the associated symptom patterns to help families prepare for their child's last week and last day.
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Affiliation(s)
- Michele Pritchard
- Division of Nursing Research, St Jude Children's Research Hospital, Memphis, Tennessee, USA
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Friberg F, Öhlen J. Searching for knowledge and understanding while living with impending death—a phenomenological case study. Int J Qual Stud Health Well-being 2009. [DOI: 10.1080/17482620701523777] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Ideals and Compromises. J Palliat Med 2006. [DOI: 10.1089/jpm.2006.9.1238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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