Health Care Policy Issues in End-of-Life Care

Impact of End-of-Life Nursing Education Consortium on Palliative Care Knowledge and Attitudes Towards Care of Dying of Nurses in India: A Quasi-Experimental Pre-post Study

Palliative care (PC) training is conspicuously absent in Indian nursing curricula which is an obstacle to deliver quality end of life care (EOLC). End of life care nursing education consortium (ELNEC) aims to improve nursing staff knowledge and attitudes in PC and EOLC, however its impact on knowledge and attitudes has not been investigated in India. We aimed to assess the impact of ELNEC on the knowledge and attitudes of nurses in India towards PC and care of the dying. This prospective study included 108 registered nurses. A pre- and post-training questionnaire containing Palliative Care Quiz of Nursing (PCQN) and Frommelt Attitude toward Care of the Dying Scale Form B (FATCOD-B) was used to evaluate the PC knowledge and attitudes towards EOLC respectively. Subgroup analysis to delineate association of baseline knowledge and attitudes with gender, educational qualification or professional experience of working with patients with cancer or chronic life limiting illnesses were done. Pre-test FATCOD-B and PCQN scores of 110.81 ± 9.37 and 8.45 ± 1.88 reflect favorable attitudes towards care of dying not backed by sufficient PC knowledge respectively. The mean PCQN and FATCOD-B scores improved from 8.45 ± 1.88 to 10.16 ± 1.89 (P = .0001) and from 110.81 ± 9.37 to 119.47 ± 10.14 (P = .0001) respectively; implying a statistically significant improvement in PC knowledge and a more positive attitudes towards care of the dying. End of life care nursing education consortium is effective in improving practicing nurses' knowledge and attitudes toward PC and care of the dying.

What Constitutes Good Health Care for Patients with Breathlessness? Perspectives of Patients, Caregivers, and Health Care Professionals

Background/Objective: Breathlessness is a highly prevalent and distressing symptom in patients with cancer and advanced chronic diseases. Symptom management is often overlooked. We explored the experiences of patients, caregivers, and health care providers (HCPs) and their expectations for future service developments. Design: This is a multiperspective qualitative study drawing on semistructured interviews. Setting/Subjects: Participants were recruited from palliative, respiratory, and cardiology departments of the Munich University Hospital and from a chronic obstructive pulmonary disease (COPD) patient group. Measurements: Interviews were analyzed using qualitative content analysis. Subcategories used the directional views of participants (positive, negative, and indifferent). The coding tree identified three categories: (1) attributes of symptom management, (2) practice pattern gaps, and (3) components of good practice. Results: Ten patients (5 female, 65.2 median age; COPD n = 3, cancer n = 3, chronic heart failure n = 2, and lung fibrosis n = 2), 3 caregivers (2 female, 53.6 median age), and 10 HCPs were interviewed. Patients and caregivers felt stressed and frustrated due to a lack of awareness regarding the symptom burden and little support from HCPs. HCPs pointed to a lack of therapeutic concepts and unclear assumptions of responsibilities. Specialist breathlessness services are perceived as addressing important gaps in professional practice from the viewpoint of all stakeholders. Accessibility and collaboration with other local health care services are important features of such specialist services. Conclusions: Chronic refractory breathlessness in advanced disease is managed insufficiently for most patients, caregivers, and HCPs. Increased knowledge about effective interventions and availability of skills-based training for patients, caregivers, and HCPs would help in breathlessness management.

Do community hospice programmes reduce hospitalisation rate in patients with advanced chronic obstructive pulmonary disease?

BACKGROUND

Since Hinton first published his observations on the distress of patients dying on a medical ward in 1963, there has been increasing awareness of the palliative care needs in patients who have non malignant diseases. Patients with advanced chronic obstructive pulmonary disease (COPD) are known to have comparable symptom burden to lung cancer patients and are more likely receive invasive treatment at the end of life than patients with end stage lung cancer. They are also less likely to receive hospice services, and the benefit of such programmes in this key group of patients remain largely unknown, in particular what effect hospice programmes have on hospitalisation.

AIMS

(i) To examine any effect of community hospice programmes on hospitalisation in patients with advanced COPD. (ii) To identify any association between utilisation of specific hospice services with hospitalisation. (iii) To describe key peri-mortem outcomes.

METHODS

This was a retrospective study of consecutive patients with COPD admitted into community hospice programmes in the greater Wellington region, New Zealand between 1 October 2007 and 31 October 2013.

RESULTS

A mean decrease of 2.375 (median decrease of 2; 95% confidence interval 1, 3) hospital admissions over a 12-month period was found after admission into hospice programme (P < 0.0005).

CONCLUSION

Community hospice programmes may be associated with reduction in hospitalisation in patients with advanced COPD.

Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND

Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED).

OBJECTIVE

The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED.

METHODS

Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement.

CONCLUSION

Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

Between Two Worlds: Liminality and Late-Stage Cancer-Directed Therapy

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.

Patient-Clinician Communication About End-of-Life Care in Patients With Advanced Chronic Organ Failure During One Year

CONTEXT

Patient-clinician communication is an important prerequisite to delivering high-quality end-of-life care. However, discussions about end-of-life care are uncommon in patients with advanced chronic organ failure.

OBJECTIVES

The aim was to examine the quality of end-of-life care communication during one year follow-up of patients with advanced chronic organ failure. In addition, we aimed to explore whether and to what extent quality of communication about end-of-life care changes toward the end of life and whether end-of-life care communication is related to patient-perceived quality of medical care.

METHODS

Clinically stable outpatients (n = 265) with advanced chronic obstructive pulmonary disease, chronic heart failure, or chronic renal failure were visited at home at baseline and four, eight, and 12 months after baseline to assess quality of end-of-life care communication (Quality of Communication questionnaire). Two years after baseline, survival status was assessed, and if patients died during the study period, a bereavement interview was done with the closest relative.

RESULTS

One year follow-up was completed by 77.7% of the patients. Quality of end-of-life care communication was rated low at baseline and did not change over one year. Quality of end-of-life care communication was comparable for patients who completed two year follow-up and patients who died during the study. The correlation between quality of end-of-life care communication and satisfaction with medical treatment was weak.

CONCLUSION

End-of-life care communication is poor in patients with chronic organ failure and does not change toward the end of life. Future studies should develop an intervention aiming at initiating high-quality end-of-life care communication between patients with advanced chronic organ failure and their clinicians.

Care planning needs of palliative home care clients: Development of the interRAI palliative care assessment clinical assessment protocols (CAPs)

BACKGROUND

The interRAI Palliative Care (interRAI PC) assessment instrument provides a standardized, comprehensive means to identify person-specific need and supports clinicians to address important factors such as aspects of function, health, and social support. The interRAI Clinical Assessment Protocols (CAPs) inform clinicians of priority issues requiring further investigation where specific intervention may be warranted and equip clinicians with evidence to better inform development of a person-specific plan of care. This is the first study to describe the interRAI PC CAP development process and provide an overview of distributional properties of the eight interRAI PC CAPs among community dwelling adults receiving palliative home care services.

METHODS

Secondary data analysis used interRAI PC assessments (N = 6,769) collected as part of regular clinical practice at baseline (N = 6,769) and follow-up (N = 1,000). Clients across six regional jurisdictions in Ontario, Canada, assessed to receive palliative homecare services between 2006 and 2011 were included (mean age 70.0 years; ±13.4 years). Descriptive analyses focused on the eight interRAI PC CAPs: Fatigue, Sleep Disturbance, Nutrition, Pressure Ulcers, Pain, Dyspnea, Mood Disturbance and Delirium.

RESULTS

The majority of clients triggered at least one CAP while two thirds triggered two or more. Triggering rates ranged from 74% for the Fatigue CAP to less than 15% for the Delirium and Pressure Ulcers CAPs. The hierarchical CAP triggering structure suggested Fatigue and Dyspnea CAPs were persistent issues prevalent among the majority of clients while Delirium and Pressure Ulcers CAPs rarely trigger in isolation and most often trigger later in the illness trajectory.

CONCLUSION

When any of the eight interRAI PC CAPs are triggered, clinicians should take notice. CAPs triggered at high rates such as fatigue, dyspnea, and pain warrant increased attention for the majority of clients. Consideration of triggered CAPs provide evidence to inform a collaborative decision making process on whether or not issues raised by the CAPs should be addressed in the plan of care. Integrating evidence from the interRAI PC CAPs into the clinical decision making process support care planning to address client strengths, preferences and needs with greater acuity.

The challenges of uncertainty and interprofessional collaboration in palliative care for non-cancer patients in the community: a systematic review of views from patients, carers and health-care professionals

BACKGROUND

Primary care has the potential to play significant roles in providing effective palliative care for non-cancer patients.

AIM

To identify, critically appraise and synthesise the existing evidence on views on the provision of palliative care for non-cancer patients by primary care providers and reveal any gaps in the evidence.

DESIGN

Standard systematic review and narrative synthesis.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, Applied Social Science Abstract and the Cochrane library were searched in 2012. Reference searching, hand searching, expert consultations and grey literature searches complemented these. Papers with the views of patients/carers or professionals on primary palliative care provision to non-cancer patients in the community were included. The amended Hawker's criteria were used for quality assessment of included studies.

RESULTS

A total of 30 studies were included and represent the views of 719 patients, 605 carers and over 400 professionals. In all, 27 studies are from the United Kingdom. Patients and carers expect primary care physicians to provide compassionate care, have appropriate knowledge and play central roles in providing care. The roles of professionals are unclear to patients, carers and professionals themselves. Uncertainty of illness trajectory and lack of collaboration between health-care professionals were identified as barriers to effective care.

CONCLUSIONS

Effective interprofessional work to deal with uncertainty and maintain coordinated care is needed for better palliative care provision to non-cancer patients in the community. Research into and development of a best model for effective interdisciplinary work are needed.

Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia

Background

To provide quality care at the end of life or for chronically sick patients, nurses must have good knowledge, attitude and practice about palliative care (PC). In Ethiopia PC is new and very little is known about the type of services offered and the readiness of nurses to provide PC.

Methods

A cross sectional quantitative study design was carried out using 341 nurses working in selected hospitals in Addis Ababa from January 2012 to May 2012. Systematic random sampling was the method employed to select two governmental and two non-governmental hospitals. The researchers used triangulation in their study method making use of: Frommelt’s Attitude Toward Care of the Dying (FATCOD) Scale, Palliative Care Quiz for Nursing (PCQN) and practice questions. This led to enhanced validity of the data. EPI-INFO and SPSS software statistical packages were applied for data entry and analysis.

Result

Of the total 365 nurses selected, a response rate of 341 (94.2%) were registered. Out of the total study participants, 104 (30.5%) had good knowledge and 259 (76%) had favorable attitude towards PC. Medical and surgical wards as well as training on PC were positively associated with knowledge of nurses. Institution, individuals’ level of education, working in medical ward and the training they took part on PC were also significantly associated with the attitude the nurses had. Nurses working in Hayat Hospital (nongovernmental) had a 71.5% chance of having unfavorable attitude towards PC than those working in Black Lion Hospital (governmental). Regarding their knowledge aspect of practice, the majority of the respondents 260 (76.2%) had poor implementation, and nearly half of the respondents had reported that the diagnosis of patients was usually performed at the terminal stage. In line with this, spiritual and medical conditions were highly taken into consideration while dealing with terminally ill patients.

Conclusion

The nurses had poor knowledge and knowledge aspect of practice, but their attitude towards PC was favorable. Recommendations are that due attention should be given towards PC by the national health policy and needs to be incorporated in the national curriculum of nurse education.

A randomised controlled trial on the efficacy of advance care planning on the quality of end-of-life care and communication in patients with COPD: the research protocol

INTRODUCTION

Recent research shows that advance care planning (ACP) for patients with chronic obstructive pulmonary disease (COPD) is uncommon and poorly carried out. The aim of the present study was to explore whether and to what extent structured ACP by a trained nurse, in collaboration with the chest physician, can improve outcomes in Dutch patients with COPD and their family.

METHODS AND ANALYSIS

A multicentre cluster randomised controlled trial in patients with COPD who are recently discharged after an exacerbation has been designed. Patients will be recruited from three Dutch hospitals and will be assigned to an intervention or control group, depending on the randomisation of their chest physician. Patients will be assessed at baseline and after 6 and 12 months. The intervention group will receive a structured ACP session by a trained nurse. The primary outcomes are quality of communication about end-of-life care, symptoms of anxiety and depression, quality of end-of-life care and quality of dying. Secondary outcomes include concordance between patient's preferences for end-of-life care and received end-of-life care, and psychological distress in bereaved family members of deceased patients. Intervention and control groups will be compared using univariate analyses and clustered regression analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from the Medical Ethical Committee of the Catharina Hospital Eindhoven, the Netherlands (NL42437.060.12). The current project provides recommendations for guidelines on palliative care in COPD and supports implementation of ACP in the regular clinical care.

CLINICAL TRIAL REGISTRATION NUMBER

NTR3940.

Integrating palliative care in severe chronic obstructive lung disease

Palliative care services for patients with chronic obstructive pulmonary disease (COPD) have been limited in most health care schemes despite the significant impact its symptoms can have on quality of life (QOL). Palliative care must be integrated to address physical and emotional distress and QOL deterioration more effectively. Multi-factorial barriers in current health care systems impede the provision of palliative care, including the lack of familiarity among health care professionals. There are sparse evidence-based studies and guidelines for clinicians to better recognize the need for palliative care in COPD patients compared to the large experience and resources available to cancer patients and hospice care. The multidisciplinary approach of palliative care should help COPD patients navigate through the continuum of chronic disease management. Highest QOL, not necessarily the highest physiologic goals, with relief of physical and emotional suffering, are most important to patients. Hospice care, the last phase of palliative care, can be offered to COPD patients when their goal of care has changed from life-prolonging therapies to comfort treatment. We suggest a scheme for identifying COPD patients for palliative care and for delivering simultaneous disease-directed care to help patients live life to the fullest. Pulmonary rehabilitation offers the best venue for incorporating palliative care. We review the need for, barriers to, and key activities for integrating palliative care into the current health care management of patients living with COPD.

Nursing home characteristics related to medicare costs for residents with and without dementia

OBJECTIVES

To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status.

DESIGN

New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes.

PARTICIPANTS

Sample of 1257 residents.

MEASURES

Records, interview, and observation.

RESULTS

Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents.

DISCUSSION

In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.