Home-based palliative care services for underserved populations

Patshitinikutau Natukunisha Tshishennuat Uitshuau (a place for Elders to spend their last days in life): a qualitative study about Innu perspectives on end-of-life care

BACKGROUND

Indigenous palliative persons and their families often have different values, spiritual traditions, and practices from Western culture and Canadian health systems. Additionally, many healthcare policies and practices have been established without adequate consultation of the Indigenous populations they are meant to serve. This can result in barriers to Innu receiving culturally safe end-of-life care. Innu community leaders from Sheshatshiu, Labrador, have identified a need for further research in this area. The purpose of this study is to: (1) describe the cultural and spiritual practices related to death and dying of the Innu in Sheshatshiu; (2) identify aspects of current end-of-life care delivery that serve and/or fail to meet the cultural and spiritual needs of the Innu in Sheshatshiu; and (3) explore ways to integrate current end-of-life care delivery practices with Innu cultural and spiritual practices to achieve culturally safer care delivery for the Innu.

METHODS

This qualitative patient-oriented research study was co-led by Innu investigators and an Innu advisory committee to conduct semi-structured interviews of 5 healthcare providers and 6 decision-makers serving the community of Sheshatshiu and a focus group of 5 Innu Elders in Sheshatshiu. Data was analyzed thematically from verbatim transcripts. The codebook, preliminary themes, and final themes were all reviewed by Innu community members, and any further input from them was then incorporated. Quotations in this article are attributed to Innu Elders by name at the Elders' request.

RESULTS

The findings are described using eight themes, which describe the following: relationships and visitation support a "peaceful death"; traditional locations of death and dying; the important role of friends and community in providing care; flexibility and communication regarding cultural practices; adequate and appropriate supports and services; culturally-informed policies and leadership; and Innu care providers and patient navigators.

CONCLUSIONS

The Innu in Sheshatshiu have a rich culture that contributes to the health, care, and overall well-being of Innu people approaching end of life. Western medicine is often beneficial in the care that it provides; however, it becomes culturally unsafe when it fails to take Innu cultural and spiritual knowledge and traditions into account.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Filipino American and Korean American Patients

As of 2019, there are 4.2 million Filipino Americans (FAs) and 1.9 million Korean Americans (KAs) in the United States, largely concentrated in New York, California, Texas, Illinois, and Washington. In both populations, similar to the broader U.S. culture, one can find health literacy gaps around understanding and utilizing palliative care. In this article, we provide 10 cultural pearls to guide clinicians on how to sensitively approach FA and KA groups when addressing palliative and end-of-life (EOL) discussions. We fully celebrate that every person is an individual and care should be tailored to each person's goals, values, and preference. In addition, there are several cultural norms that, when appreciated and celebrated, may help clinicians to improve serious illness care and EOL discussions for members of these populations.

Exploring the challenges and roles of nurses in delivering palliative care for cancer patients and co-morbidities in Ghana

BACKGROUND

Patients suffering from chronic and life-threatening diseases receive inadequate palliative care in low-income countries, eventually leading to poor quality of life for these patients. Little is known about the experience of delivering palliative care in a low-resource country such as Ghana in comparison to higher-income countries. This study, therefore, aimed to assess the roles and challenges of nurses providing palliative care services for patients with cancer and life-limiting conditions at tertiary Hospitals in Ghana.

METHODS

Thirty oncology nurses at a tertiary Hospital in Ghana participated. All nurses were providing end-of-life care to patients with cancer. A qualitative exploratory-descriptive design and a semi-structured interview guide developed by the researchers were used. Interviews lasted on average forty minutes to 1 h were audio-recorded, and transcribed verbatim. Content analysis was carried out to generate themes and sub-themes.

FINDINGS

Participants were between the ages of 25 and 40 years. A higher percentage of females (n = 17, 57%) participated in the study than males (n = 13, 43%). Two main themes were generated which were the delivery of palliative care and the provision of home care services. The current roles of nurses were centered around pain management, home care services, spiritual needs, and psychological care. Challenges that hindered the implementation of palliative care included distress over expected and unexpected patient mortality, difficulty delivering bad news to patients and families, and frustration with health system resource shortages that negatively impacted patient care.

CONCLUSION

Palliative care is one of the essential services provided for patients with life-limiting conditions, and nurses play an active role in the provision of this care. Further research is needed to determine the most effective ways to deliver this care, particularly in developing nations like Ghana.

The effect of end-of-life decision-making tools on patient and family-related outcomes of care among ethnocultural minorities: A systematic review

Background

End-of-life decision-making tools are used to establish a shared understanding among patients, families and healthcare providers about medical treatment and goals of care. This systematic review aimed to understand the availability and effect of end-of-life decision-making tools on: (i) goals of care and advance care planning; (ii) patient and/or family satisfaction and well-being; and (iii) healthcare utilization among racial/ethnic, cultural, and religious minorities.

Methods

A search was conducted in four electronic databases (inception to June 2021). Articles were screened for eligibility using pre-specified criteria. We focused on adult patients (aged ≥18 years) and included primary research articles that used quantitative, qualitative, and mixed-methods designs. Complementary quality assessment tools were used to generate quality scores for individual studies. Extracted data were synthesized by outcome measure for each type of tool, and an overall description of findings showed the range of effects.

Results

Among 14,316 retrieved articles, 37 articles were eligible. We found that advance care planning programs (eleven studies), healthcare provider-led interventions (four studies), and linguistically-tailored decision aids (three studies) increased the proportion of patients documenting advance care plans. Educational tools (three studies) strongly reduced patient preferences for life-prolonging care. Palliative care consultations (three studies) were strongly associated with do-not-resuscitate orders. Advance care planning programs (three studies) significantly influenced the quality of patient-clinician communication and healthcare provider-led interventions (two studies) significantly influenced perceived patient quality of life.

Conclusion

This review identified several end-of-life decision-making tools with impact on patient and family-related outcomes of care among ethnocultural minorities. Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care. Further research is needed to investigate the effect of tools on healthcare utilization, and with specific patient population subgroups across different illness trajectories and healthcare settings.

Factors Influencing Public Awareness of and Attitudes Toward Palliative Care: A Cross-Sectional Analysis of the 2018 HINTS Data

Background

The global burden of serious health-related suffering requiring palliative care has been projected to grow significantly by 2060, which indicates the imminent need for integrating palliative care into health systems globally. Moreover, research evidence has been accumulating in support of the earlier adoption of palliative care into the treatment course of serious life-threatening illnesses. However, barriers to earlier access to palliative care still remain, which might be attributable to the global lack of awareness of palliative care and the prevalence of negative perceptions and attitudes. To address this, further investigation of the influencing factors of public perceptions of palliative care is imperative to help inform and develop effective targeted public health campaigns and education messages aimed at improving views of palliative care and thereby early access.

Methods

We used data from the Health Information National Trends Survey (HINTS), a nationally representative cross-sectional survey routinely administrated by the National Cancer Institute from the United States. Specifically, we analyzed the latest palliative care data from HINTS 5 Cycle 2 data set. Sociodemographic characteristics, individual factors such as self-perceived health status, and interpersonal factors such as relationship quality were examined as predictors of public awareness of and attitudes toward palliative care. Survey data were analyzed using SPSS 26 with multiple hierarchical regression tests.

Results

Results showed that people's quality of interpersonal relationships was a significant influencing factor of their awareness of and attitudes toward palliative care. Moreover, cancer diagnosis history and perceived healthcare quality were found to jointly affect their awareness of palliative care; perceived health status and patient centeredness interacted to influence their awareness of and attitudes toward palliative care. Finally, female, non-white, and poorer people were more aware of palliative care, while female and more educated people had more favorable attitudes.

Conclusions

The quality of social relationships emerges as a significant predictor of people's awareness of and attitude toward palliative care, as treatment options and decisions of serious life-threatening illnesses often involve the patients' family. The results hold strong implications for public health campaigns and education messages aiming at changing people's views of palliative care, which ultimately improve end-of-life outcomes.

Advance Care Planning, Palliative Care, and End-of-life Care Interventions for Racial and Ethnic Underrepresented Groups: A Systematic Review

CONTEXT

Persons from underrepresented racial and ethnic groups experience disparities in access to and quality of palliative and end-of-life care.

OBJECTIVES

To summarize and evaluate existing palliative and end-of-life care interventions that aim to improve outcomes for racial and ethnic underrepresented populations in the United States.

METHODS

We conducted a systematic review of the literature in the English language from four databases through January 2020. Peer-reviewed studies that implemented interventions on palliative care, advance care planning, or end-of-life care were considered eligible. Data were extracted from 16 articles using pre-specified inclusion and exclusion criteria. Quality was appraised using the modified Downs and Black tool for assessing risk of bias in quantitative studies.

RESULTS

Five studies were randomized controlled trials, and the remainder were quasi-experiments. Six studies targeted Latino/Hispanic Americans, five African Americans, and five, Asian or Pacific Islander Americans. The two randomized control trials reviewed and rated "very high" quality, found educational interventions to have significant positive effects on advance care planning and advance directive completion and engagement for underrepresented racial or ethnic groups.

CONCLUSION

The effectiveness of advance care planning, end-of-life, and palliative care interventions in improving outcomes for underrepresented racial and ethnic populations remains uncertain. Randomized controlled trials and educational interventions indicate that interventions targeting underrepresented groups can have significant and positive effects on advance directives and/or advance care planning-related outcomes. More high-quality intervention studies that address racial and ethnic health disparities in palliative care are needed, particularly those that address systemic racism and other complex multilevel factors that influence disparities in health.

The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study

OBJECTIVE

Completion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy.

METHODS

A randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months.

RESULTS

Five hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups.

CONCLUSION

A brief intervention had no impact on AD completion for subjects of adequate or limited health literacy.

PRACTICE IMPLICATIONS

Our intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids.

TRIAL REGISTRATION NUMBER

NCT02702284, Protocol ID IRB201500776.

End-of-life care for older first-generation migrants: a scoping review

BACKGROUND

The unprecedented scale of contemporary migration across countries over the last decade means that ageing and dying occur in a more globalised, multicultural context. It is therefore essential to explore the end-of-life experiences of older people from migrant backgrounds.

METHODS

A scoping review of peer-reviewed articles published in English from 2008 to 2018. Included studies addressed end-of-life preferences, attitudes, values and beliefs of first-generation international migrants who were at least 50 years of age.

RESULTS

Fifteen studies met the inclusion criteria for this review, which addressed six key themes: (1) the reluctance among older migrants and their families to talk about death and dying; (2) difficult communication in patient-clinician relationships; (3) the contrast between collectivistic and individualistic norms and its associated end-of-life preferences; (4) limited health literacy in older adults from migrant backgrounds; (5) experiences with systemic barriers like time pressure, inflexibility of service provision and lack of cultural sensitivity and (6) the need for care providers to appreciate migrants' 'double home experience' and what this means for end-of-life decision-making regarding place of care and place of death.

DISCUSSION

To respond effectively to an increasingly culturally diverse population, healthcare staff, researchers and policymakers need to invest in the provision of culturally sensitive end-of-life care. Areas for improvement include: (a) increased awareness of cultural needs and the role of family members; (b) cultural training for healthcare staff; (c) access to interpreters and translated information and (d) involvement of older migrants in end-of-life discussions, research and policymaking.

Supportive Care for Superutilizers of a Managed Care Organization

Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.

Understanding family caregivers' needs to support relatives with advanced progressive disease at home: an ethnographic study in rural Portugal

Background

Family caregivers play an important role supporting their relatives with advanced progressive disease to live at home. There is limited research to understand family caregiver needs over time, particularly outside of high-income settings. The aim of this study was to explore family caregivers’ experiences of caring for a relative living with advanced progressive disease at home, and their perceptions of met and unmet care needs over time.

Methods

An ethnographic study comprising observations and interviews. A purposive sample of 10 family caregivers and 10 relatives was recruited within a rural area in the north of Portugal. Data were collected between 2014 and 16 using serial participant observations (n = 33) and in-depth interviews (n = 11). Thematic content analysis was used to analyse the data.

Results

Five overarching themes were yielded: (1) provision of care towards independence and prevention of complications; (2) perceived and (3) unknown caregiver needs; (4) caregivers’ physical and emotional impairments; and (5) balancing limited time. An imbalance towards any one of these aspects may lead to reduced capability and performance of the family caregiver, with increased risk of complications for their relative. However, with balance, family caregivers embraced their role over time.

Conclusions

These findings enhance understanding around the needs of family caregivers, which are optimally met when professionals and family caregivers work together with a collaborative approach over time. Patients and their families should be seen as equal partners. Family-focused care would enhance nursing practice in this context and this research can inform nursing training and educational programs.

A Review of the Literature on Native Hawaiian End-of-Life Care: Implications for Research and Practice

The need for cultural understanding is particularly important in end-of-life (EOL) care planning as the use of EOL care in minority populations is disproportionately lower than those who identify as Caucasian. Data regarding the use of EOL care services by Native Hawaiians in Hawai'i and the United States is limited but expected to be similarly disproportionate as other minorities. In a population with a lower life expectancy and higher prevalence of deaths related to chronic diseases such as cardiovascular disease, diabetes, and obesity, as compared to the state of Hawai'i as a whole, our objective was to review the current literature to understand the usage and perceptions of EOL care planning in the Native Hawaiian population. We searched ten electronic databases and after additional screening, seven articles were relevant to our research purpose. We concluded that limited data exists regarding EOL care use specifically in Native Hawaiians. The available literature highlighted the importance of understanding family and religion influences, educating staff on culturally appropriate EOL care communication, and the need for more research on the topic. The paucity of data in EOL care and decision-making in Native Hawaiians is concerning and it is evident this topic needs more study. From national statistics it looks as though this is another health disparate area that needs to be addressed and is especially relevant when considering the rapid increase in seniors in our population.

Methods for overcoming barriers in palliative care for ethnic/racial minorities: a systematic review

OBJECTIVES

Ethnic/racial minority groups are less likely to discuss issues involving end-of-life treatment preferences and utilize palliative care or hospice services. Some barriers may be differences in language, religion, lower levels of health literacy, or less access to healthcare services and information. The purpose of this article is to conduct a systematic review on interventional studies that investigated methods to overcome the barriers faced by ethnic/racial minorities when accessing end-of-life services, including completing advanced directives, accepting palliative care, and enrolling in hospice.

METHODS

Literature searches using four standard scientific search engines were conducted to retrieve articles detailing original research in an interventional trial design. All studies were conducted in an outpatient setting, including primary care visits, home visits, and dialysis centers. Target populations were those identified from ethnic or racial minorities.

RESULTS

Nine articles were selected to be included in the final review. All were full-text English language articles, with target populations including African Americans, Hispanic or Latinos, and Asian or Pacific Islanders. Measured outcomes involved level of comfort in discussing and knowledge of palliative care services, desire for aggressive care at the end-of-life, completion of advance directives, and rate of enrollment in hospice.

SIGNIFICANCE OF RESULTS

Three main avenues of interventions included methods to enhance patient education, increase access to healthcare, or improve communication to establish better rapport with target population. Studies indicate that traditional delivery of healthcare services may be insufficient to recruit patients from ethnic/racial minorities, and outcomes can be improved by implementing tailored interventions to overcome barriers.

Informal Caregiving in a Medically Underserved Community: Challenges, Construction of Meaning, and the Caregiver-Recipient Dyad

Little is known about informal caregivers' challenges in medically underserved communities. This qualitative study explores their perceptions/experiences of caregiving in a medically underserved community in Midwest United States. Two focus groups (n = 12) were conducted and themes were extracted and analyzed. Theme 1 included perceived barriers/unmet needs; most prevalent of which were lack of informational resources and support groups. A second unsolicited and unanticipated theme highlighted how caregivers constructed meaning through reappraising challenges to create enriching experiences for themselves, reinforcing their evolving dyadic relationship with care-recipient. Challenging and enriching aspects of caregiving coexisted and were rooted in caregiver-care-recipient dyad. Caregivers used meaning-making as a coping strategy for challenges. Prior research corroborates caregivers' challenges and meaning-making; this study contributes by delineating how both become interrelated. Policy makers can (a) alleviate challenges by increasing informational resources and support groups and (b) provide training to optimize caregivers' meaning-making, thus enhancing their positive experiences.

Identifying Palliative Care Needs Among Older Adults in Nonclinical Settings

Though palliative care is appropriate for patients with serious illness at any stage of the illness and treatment process, the vast majority of palliative care is currently delivered in inpatient medical settings in the past month of life during an acute hospitalization. Palliative care can have maximal benefit to patients when it is integrated earlier in the illness trajectory. One possible way to increase earlier palliative care use is to screen for unmet palliative care needs in community settings. The goal of this study was to assess the rates of unmet palliative care needs in older adults who attend New York City-based senior centers. The results of this study revealed that 28.8% of participants screened positive for unmet palliative care needs. Lower education and living alone were predictors of positive palliative care screens, but age, gender, marital status, and race were not. This study determined that the rate of unmet palliative care needs in community-based older adults who attend senior center events was high and that living arrangement and education level are both correlates of unmet palliative care needs. Screening for unmet palliative care needs in community settings is a promising approach for moving palliative care upstream to patients who could benefit from the additional supportive services prior to an acute hospitalization.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Key features of palliative care service delivery to Indigenous peoples in Australia, New Zealand, Canada and the United States: a comprehensive review

Background

Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern.

Objectives

To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples’ preferences, needs, opportunities and barriers to palliative care.

Methods

A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly’s hierarchy of evidence-for-practice in qualitative research.

Results

Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples’ experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements.

Conclusions

The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0325-1) contains supplementary material, which is available to authorized users.

Priorities and challenges for a palliative approach to care for rural indigenous populations: A scoping review

We carried out a scoping review to identify key priorities and challenges relevant to rural Indigenous palliative care stated in existing literature. Our scoping review activities followed Arskey and O'Malley's principles for conducting a scoping review. We included peer-reviewed literature from MEDLINE, CINAHL and EMBASE that included a discussion of Indigenous populations, palliative care, and rural settings, and did not use date limits. The literature search was conducted in April 2016, and the retrieved literature was screened for relevance and appropriateness April 2016-March of 2017. In addition to the academic literature, a scan of the grey literature was conducted in March 2017. The retrieved grey literature was screened for relevance and reviewed by a team from a provincial health authority serving Indigenous peoples to ensure relevance in a rural BC setting. Once reviewed for relevance and appropriateness, we added four reports to supplement our analysis. Ultimately, 44 peer-reviewed articles and 4 pieces of grey literature met our inclusion criteria and were included in the review. Our analysis revealed several challenges and priorities relevant to rural Indigenous palliative care. Key challenges included: (i) environmental and contextual issues; (ii) institutional barriers; and (iii) interpersonal dynamics challenging client/clinician interactions. Priorities included: (i) family connections throughout the dying process; (ii) building local capacity for palliative care to provide more relevant and culturally appropriate care; and (iii) flexibility and multi-sectoral partnerships to address the complexity of day-to-day needs for patients/families. These findings point to several areas for change and action that can improve the relevance, access and comprehensiveness of palliative care programming for rural Indigenous communities in Canada and elsewhere. Taking into account of the diversity and unique strengths of each Indigenous community will be vital in developing sustainable and meaningful change.

Palliative care in the home: a scoping review of study quality, primary outcomes, and thematic component analysis

Background

The aim of palliative care is to improve the quality of life of patients and families through the prevention and relief of suffering. Frequently, patients may choose to receive palliative care in the home. The objective of this paper is to summarize the quality and primary outcomes measured within the palliative care in the home literature. This will synthesize the current state of the literature and inform future work.

Methods

A scoping review was completed using PRISMA guidelines. PubMed, Embase, CINAHL, Web of Science, Cochrane Library, EconLit, PsycINFO, Centre for Reviews and Dissemination, Database of Abstracts of Reviews of Effects, and National Health Service Economic Evaluation Database were searched from inception to August 2016. Inclusion criteria included: 1) care was provided in the “home of the patient” as defined by the study, 2) outcomes were reported, and 3) reported original data. Thematic component analysis was completed to categorize interventions.

Results

Fifty-three studies formed the final data set. The literature varied extensively. Five themes were identified: accessibility of healthcare, caregiver support, individualized patient centered care, multidisciplinary care provision, and quality improvement. Primary outcomes were resource use, symptom burden, quality of life, satisfaction, caregiver distress, place of death, cost analysis, or described experiences. The majority of studies were of moderate or unclear quality.

Conclusions

There is robust literature of varying quality, assessing different components of palliative care in the home interventions, and measuring different outcomes. To be meaningful to patients, these interventions need to be consistently evaluated with outcomes that matter to patients. Future research could focus on reaching a consensus for outcomes to evaluate palliative care in the home interventions.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0299-z) contains supplementary material, which is available to authorized users.

Hospice volunteers: bridging the gap to the community?

Current demographic, policy and management changes are a challenge to hospices to develop their volunteering practices. The study upon which this paper is based aimed to explore good practice in volunteer involvement and identify ways of improving care through developing volunteering. The project consisted of a narrative literature review; a survey of volunteer managers; and organisational case studies selected through purposive diversity sampling criteria. A total of 205 staff, volunteers, patients and relatives were interviewed across 11 sites in England in 2012. This article focuses on one of the findings - the place that volunteers occupy between the hospice and the community beyond its walls. External changes and pressures in society were impacting on volunteer management, but were viewed as requiring a careful balancing act to retain the 'spirit' of the hospice philosophy. Honouring the developmental history of the hospice was vital to many respondents, but viewed less positively by those who wished to modernise. Hospices tend to be somewhat secluded organisations in Britain, and external links and networks were mostly within the end-of-life care arena, with few referring to the wider volunteering and community fields. Volunteers were seen as an informal and symbolic 'link' to the local community, both in terms of their 'normalising' roles in the hospice and as providing a two-way flow of information with the external environment where knowledge of hospice activities remains poor. The diversity of the community is not fully represented among hospice volunteers. A few hospices had deliberately tried to forge stronger interfaces with their localities, but these ventures were often controversial. The evidence suggests that there is substantial scope for hospices to develop the strategic aspects of volunteering through greater community engagement and involvement and by increasing diversity and exploiting volunteers' 'boundary' position more systematically to educate, recruit and raise awareness.

Expanding palliative care's reach in the community via the elder service agency network

Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

CONTEXT

Community-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models.

OBJECTIVES

To evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles.

METHODS

A retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010-2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization.

RESULTS

The mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40-70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time.

CONCLUSION

The population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.

Self-reported impact of caregiving on voluntary home-based caregivers in Mutale Municipality, South Africa

Background

The establishment of home-based care (HBC) programmes in developing countries has resulted in a shift of burden from hospitals to communities where palliative care is provided by voluntary home-based caregivers.

Aim

The study investigated the impact of caregiving on voluntary home-based caregivers.

Setting

The study was conducted at HBC organisations located in Mutale Municipality of Limpopo Province, South Africa.

Methods

A quantitative cross-sectional descriptive survey design was applied to investigate the impact of caregiving on voluntary home-based caregivers. The sample was comprised of (N = 190) home-based caregivers. Home-based caregivers provide care to people in need of care in their homes, such as orphans, the elderly and those suffering from chronic illnesses such as tuberculosis, HIV and/or AIDS, cancer and stroke. Self-administered questionnaires were used to collect data which were analysed descriptively using the Statistical Package for the Social Sciences software, Version 20.

Results

The results showed that 101 (53.2%) participants were worried about their financial security because they were not registered as workers, whilst 74 (39.0%) participants were always worried about getting infection from their clients because they often do not have protective equipment.

Conclusion

Voluntary home-based caregivers have an important role in the provision of palliative care to people in their own homes, and therefore, the negative caregiving impact on the lives of caregivers may compromise the provision of quality palliative care.

Pilot Testing of Triage Coding System in Home-based Palliative Care Using Edmonton Symptom Assessment Scale

INTRODUCTION

Home-based palliative care is an essential model of palliative care that aims to provide continuity of care at patient's own home in an effective and timely manner. This study was a pilot test of triage coding system in home-based palliative care using Edmonton Symptom Assessment System (ESAS) scale.

METHODS

Objective of the study was to evaluate if the triage coding system in home-based palliative care: (a) Facilitated timely intervention, (b) improved symptom control, and (c) avoided hospital deaths. Homecare services were coded as high (Group 1 - ESAS scores ≥7), medium (Group 2 - ESAS scores 4-6), and low (Group 3 - ESAS scores 0-3) priority based on ESAS scores. In high priority group, patients received home visit in 0-3 working days; medium priority group, patients received home visit in 0-10 working days; and low priority group, patients received home visit in 0-15 working days. The triage duration of home visit was arbitrarily decided based on the previous retrospective audit and consensus of the experts involved in prioritization and triaging in home care.

RESULTS

"High priority" patients were visited in 2.63 ± 0.75 days; "medium priority" patients were visited in 7.00 ± 1.5 days, and "low priority" patients were visited in 10.54 ± 2.7 days. High and medium priority groups had a statistically significant improvement in most of the ESAS symptoms following palliative home care intervention. Intergroup comparison showed that improvement in symptoms was the highest in high priority group compared to medium and low priority group. There was an 8.5% increase in home and hospice deaths following the introduction of triage coding system. There was a significant decrease in deaths in the hospital in Group 1 (6.3%) (χ (2) = 27.3, P < 0.001) compared to Group 2 (28.6%) and Group 3 (15.4%). Group 2 had more hospital deaths. Interval duration from triaging to first intervention was a significant predictor of survival with odds ratio 0.75 indicating that time taken for intervention from triaging was more significantly affecting survival than group triaging.

CONCLUSION

Pilot study of testing triaging coding system in home-based palliative care showed, triage coding system: (a) Facilitated early palliative home care intervention, (b) improved symptom control, (c) decreased hospital deaths, predominantly in high priority group, and (d) time taken for intervention from triaging was a significant predictor of survival.

Quality of hospice care: comparison between rural and urban residents

Discrepancies between needed and received hospice care exist, especially in rural areas. Hospice care quality ratings for 743 rural and urban patients and their families were compared. Rural participants reported higher overall satisfaction and with pain/symptom management. Regardless of geographic location, satisfaction was higher when patients were informed and emotionally supported. Patients and family ratings did not differ. Findings support prior reports using retrospective rather than our study's point-of-care surveys.

Community-based palliative care: the natural evolution for palliative care delivery in the U.S

Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).

A narrative literature review of the contribution of volunteers in end-of-life care services

BACKGROUND

Volunteers are integral to the history of hospices and continue to play a vital role. However, economic, policy and demographic challenges in the twenty-first century raise questions about how best to manage this essential resource.

AIM

This narrative review explores the recent literature on end-of-life care volunteering and reflects upon the issues pertinent to current organisational challenges and opportunities.

DESIGN

The parameters of the review were set deliberately wide in order to capture some of the nuances of contemporary volunteer practices. Articles reporting on research or evaluation of adult end-of-life care services (excluding prison services) that use volunteers and were published in English between 2000 and 2011 were included.

DATA SOURCES

Seven electronic databases, key journals and grey literature databases.

RESULTS

Sixty-eight articles were included in the analysis. The articles were drawn from an international literature, while acknowledging that volunteer roles vary considerably by organisation and/or by country and over time. The majority of articles were small in scale and diverse in methodology, but the same topics repeatedly emerged from both the qualitative and quantitative data. The themes identified were individual volunteer factors (motivation, characteristics of volunteers, stress and coping, role boundaries and value) and organisational factors (recruiting for diversity, support and training and volunteers' place in the system).

CONCLUSIONS

The tensions involved in negotiating the boundary spaces that volunteers inhabit, informality and regulation, diversity issues and the cultural specificity of community models, are suggested as topics that merit further research and could contribute to the continuing development of the volunteer workforce.

Do community specialist palliative care services that provide home nursing increase rates of home death for people with life-limiting illnesses? A systematic review and meta-analysis of comparative studies

CONTEXT

Systematic reviews and meta-analyses suggest that community specialist palliative care services (SPCSs) can avoid hospitalizations and enable home deaths. But more information is needed regarding the relative efficacies of different models. Family caregivers highlight home nursing as the most important service, but it is also likely the most costly.

OBJECTIVES

To establish whether community SPCSs offering home nursing increase rates of home death compared with other models.

METHODS

We searched MEDLINE, AMED, Embase, CINAHL, the Cochrane Database of Systematic Reviews, and CENTRAL on March 2 and 3, 2011. To be eligible, articles had to be published in English-language peer-reviewed journals and report original research comparing the effect on home deaths of SPCSs providing home nursing vs. any alternative. Study quality was independently rated using Cochrane grades. Maximum likelihood estimation of heterogeneity was used to establish the method for meta-analysis (fixed or random effects). Potential biases were assessed.

RESULTS

Of 1492 articles screened, 10 articles were found eligible, reporting nine studies that yielded data for 10 comparisons. Study quality was high in two cases, moderate in three and low in four. Meta-analysis indicated a significant effect for SPCSs with home nursing (odds ratio 4.45, 95% CI 3.24-6.11; P<0.001). However, the high-quality studies found no effect (odds ratio 1.40, 95% CI 0.97-2.02; P=0.071). Bias was minimal.

CONCLUSION

A meta-analysis found evidence to be inconclusive that community SPCSs that offer home nursing increase home deaths without compromising symptoms or increasing costs. But a compelling trend warrants further confirmatory studies. Future trials should compare the relative efficacy of different models and intensities of SPCSs.

Symptom burden in chronically ill homebound individuals

OBJECTIVES

To document the degree of symptom burden in an urban homebound population.

DESIGN

Cross-sectional survey.

SETTING

The Mount Sinai Visiting Doctors (MSVD) program.

PARTICIPANTS

All individuals newly enrolled in the MSVD.

MEASUREMENTS

Edmonton Symptom Assessment Scale (ESAS), which consists of 10 visual analogue scales scored from 0 to 10; symptoms include pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, shortness of breath, and other.

RESULTS

ESAS scores were completed for 318 participants. Most participants were aged 80 and older (68%) and female (75%); 36% were white, 22% black, and 32% Hispanic. Forty-three percent had Medicaid, and 32% lived alone. Ninety-one percent required assistance with one or more activities of daily living, 45% had a Karnofsky Performance Scale score between 0 and 40 (unable to care for self), and 43% reported severe burden on one or more symptoms. The most commonly reported symptoms were loss of appetite, lack of well-being, tiredness, and pain; the symptoms with the highest scores were depression, pain, appetite, and shortness of breath. Participants were more likely to have severe symptom burden if they self-reported their ESAS, had chronic obstructive pulmonary disease or diabetes mellitus with end organ damage, or had a Charlson Comorbidity Index greater than 3 and less likely to have severe burden if they had dementia.

CONCLUSION

In chronically ill homebound adults, symptom burden is a serious problem that needs to be addressed alongside primary and specialty care needs.

Racial/ethnic perspectives on the quality of hospice care

Diversity in the US population is increasing, and evaluating the quality of culturally sensitive hospice care is important. A survey design was used to collect data from 743 patients enrolled in hospice or their family members or caregivers. Race/ethnicity was not significantly associated with any of the hospice interventions or outcomes. Patients were less likely to be satisfied with the overall hospice care (OR = 0.23, 95% CI = 0.065-0.796, P = .021) compared to other type of respondents.  Satisfaction with emotional support was substantially associated with the increased likelihood of satisfaction with pain management (OR = 3.82, 95% CI = 1.66-8.83, P = .002), satisfaction with other symptom management (OR = 6.17, 95% CI = 2.80-13.64, P < .001), and of overall satisfaction with hospice care (OR = 20.22, 95% CI = 8.64-47.35, P < .001).

Palliative care needs of patients with cancer living in the community

PURPOSE

With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice.

METHODS

This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011.

RESULTS

The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms.

CONCLUSIONS

Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.

Pain outcomes of inpatient pain and palliative care consultations: differences by race and diagnosis

BACKGROUND

Pain management disparities exist among patients not receiving palliative care. We examined pain outcomes for disparities among patients receiving palliative care.

METHODS

At a 542-bed teaching hospital in Honolulu, The Queens' Medical Center Pain and Palliative Care Department collected patient characteristics and pain severity (initial, final) for each consultation from 2005 through 2009. Analyses compared pain levels by race (white, Asian, Hawaiian/Pacific Islander [PI], other) and consultation diagnosis (cancer, noncancer medical, surgical [59% orthopedic], other). Multiple regression models analyzed factors associated with lower final pain levels and pain reduction.

RESULTS

Study population included 4658 patients. No final pain was reported by more non-white patients (33%-39%) than white (27%, p<0.0001) and more cancer and noncancer medical patients (45%-54%) than surgical/other patients (20%-31%, p<0.0001). Asian (adjusted odds ratio [aOR] 1.24; 95% confidence interval [CI] 1.06-1.46; p=0.007) and PI (aOR 1.46, 95% CI 1.20-1.77, p=0.0001) races had increased likelihoods of lower final pain severity versus whites, controlling for age, gender, Karnofsky score, preconsult length of stay, and initial pain severity. Surgical diagnoses had decreased likelihood of lower final pain levels versus cancer (aOR 0.38, 95% CI 0.32-0.46, p<0.0001). Among 2304 patients reporting moderate/severe initial pain, 1738 (75.4%) reported pain reduction to mild/no final pain. PI race was associated with pain reduction versus whites (aOR 1.57, 95% CI 1.17-2.10, p=0.003). Surgical diagnoses had decreased likelihood of pain reduction vs. cancer (aOR 0.52, 95% CI 0.39-0.71, p<0.0001).

CONCLUSION

Pain outcomes were similar or better among non-white races than whites. Surgical patients reported more final pain than cancer patients.

Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer

CONTEXT

Intensive palliative care consultations for plan of care may reduce racial differences in end-of-life care.

OBJECTIVES

To compare cancer patients' hospice referrals and code status changes after inpatient palliative care consultations by patient ethnicity and consultation intensity.

METHODS

This observational cohort study prospectively recorded data for all adult cancer patients receiving palliative care consultations at the largest teaching hospital in Hawaii from 2005 through 2009. Chi-squared analyses compared hospice referral and code status changes with "Do Not Attempt Resuscitation" by patient characteristics and consultation intensity (more intensive plan of care vs. pain and/or symptom management without plan of care). Multiple logistic regression models analyzed factors associated with hospice referral and code status change.

RESULTS

The 1362 consultations generated 454 (33.3%) hospice referrals and 234 (17.2%) code status changes. Controlling for age, gender, Karnofsky score, and preconsultation hospital days, Asian, Pacific Islander, and "other" ethnicities demonstrated increased likelihood of hospice referral vs. whites (adjusted odds ratios [AORs] 1.46-2.34, P<0.05). Intensive plan-of-care consultations were strongly associated with hospice referral (AOR 3.08, 95% confidence interval [CI] 2.33-4.07, P<0.0001). Controlling for consultation intensity reduced the association between ethnicity and hospice referral (AORs 1.35-2.06, P=0.03, "other" ethnicity; P=nonsignificant, Asian and Pacific Islander). Intensive consultations were strongly associated with code status change (AOR 2.96; 95% CI 2.08-4.22, P<0.0001). Ethnicity was not significantly associated with code status change.

CONCLUSION

Consultation intensity was the strongest predictor of hospice referrals and code status changes and reduced the ethnic variations associated with hospice referral.