Death, Dying, and Dignity in the Time of the COVID-19 Pandemic

Family Experiences of Loss and Bereavement in Palliative Care Units during the COVID-19 Pandemic: An Interpretative Phenomenological Study

The COVID-19 pandemic significantly interrupted the grieving experiences of bereaved families and drastically changed their ways of dealing with loss. Our study aims to gain an in-depth understanding of the experience of bereaved relatives of patients who died in palliative care units during the COVID-19 pandemic. The phenomenological research design included sixteen family members of hospitalized palliative patients who died from November 2021 to June 2022. The study involved conducting qualitative in-depth semi-structured interviews with family members 12-24 months after the death of their loved ones. The interviews aimed to gather information about the experiences of the families both before and after the death. The COREQ guidelines were applied in the study. Participants were mainly female (n = 13) with a mean age of 47.25 (SD = 12.58). Data were analysed using the Interpretative Phenomenology Analysis (IPA). The following three categories were identified: (1) navigating loved ones' final weeks and days (troubled deaths); (2) the last farewell was robbed; (3) looking for adjustment after loss. One overall main theme emerged, which was as follows: "Struggling between stolen moments and painful losses to get back into the flow of life". This study provides novel insights into end-of-life care and bereavement from the perspectives of family. Our findings suggest that developing and promoting family-centred culture can lead to compassionate palliative care focused on a myriad ways of affirming that their loved one matters.

Intensive Care Nurses' Anxiety About COVID-19, Approaches to and Attitudes Toward Dying with Dignity Principles During the Pandemic

While trying to protect themselves from COVID-19, intensive care nurses saved many patients by providing care during the pandemic. The aim of this study is to determine the anxiety levels of nurses working in intensive care units about COVID-19, attitudes toward and approaches to end-of-life care, and attitudes toward dying with dignity. This cross-sectional descriptive study was carried out with 144 nurses. The Attitudes and Behaviors of ICU Nurses Intended for End-of-Life Care Scale, Attitudes towards Principles about Dying with Dignity Scale and COVID-19 Anxiety Scale were used to collect data. The mean age of the nurses was 30.02 ± 6.02. 63.80% of them were women and 62.20% of them worked in the internal intensive care unit. While the participants supported the principles of dying with dignity, their attitudes and approach to end-of-life care were at a good level, and COVID-19 anxiety was at a low level. Participants mostly adopted the protection of human dignity and privacy principles. Attitudes and approaches to end-of-life care and attitudes toward dying with dignity were not affected by COVID-19 anxiety.

End-Of-Life Cancer Patients' Dignity Perception Before and During COVID-19 Pandemic

Background: The safety and restriction regulations implemented to contain the COVID-19 pandemic significantly impacted people's quality of life compromising the perception of dignity. Preserving dignity for end-of-life patients remains a paramount objective in palliative care. This study aimed to compare dignity levels in terminal cancer patients between pre- and during-pandemic periods. Methods: Dignity was assessed by the Italian version of the Patient Dignity Inventory (PDI-IT) in both pre- and during-pandemic groups of terminal cancer inpatients (hospitalized or admitted in hospice). The 2 groups were compared using non-parametric tests and a multivariate logistic regression analysis to estimate the association of the different dimensions of dignity with COVID-19 period, adjusting for other confounders. The study involved 2 groups of end-of-life cancer patients with a Karnofsky Performance Status (KPS) index less than 50. The first group included 506 patients before COVID-19, and the second group consisted of 156 patients enrolled during pandemic. Results: Existential Distress, Loss of Purpose and Meaning, Physical Symptoms and Dependency, Social Support PDI subscales and PDI Total score were higher in the during-pandemic group. The multivariate regression model partially supported the previous results as Loss of Purpose and Meaning, Social Support, and Existential Distress PDI subscales were associated with during-pandemic period, whereas PDI Physical Symptoms and Dependency and PDI Psychological Distress were not. Conclusion: Social isolation and other restrictions put in place to contain the COVID-19 pandemic may have had a negative impact on the perception of dignity in cancer patients at the end of life.

The first casualty of COVID-19 for patients nearing death was human dignity: Understanding the experience of palliative care patients during the COVID-19 pandemic

The COVID-19 pandemic changed the way people lived, but also the way they died. It accentuated the physical, psychological, social, and spiritual vulnerabilities of patients approaching death. This study explored the lived experience of palliative inpatients during the pandemic. We conducted interviews with 22 palliative inpatients registered in a Canadian urban palliative care program, aimed to uncover how the pandemic impacted participants' experiences of approaching end-of-life. The reflexive thematic analysis revealed 6 themes: putting off going into hospital, the influence of the pandemic on hospital experience, maintaining dignity in care, emotional impact of nearing death, making sense of end-of-life circumstances and coping with end-of-life. Findings highlight the vulnerability of patients approaching death, and how that was accentuated during the pandemic. Findings reveal how the pandemic strained, threatened, and undermined human connectedness. These lived experiences of palliative inpatients offer guidance for future pandemic planning and strategies for providing optimal palliative care.

Applying Lessons From Ars Moriendi to Foster Dying Well in Acute Care Settings

Medical and technological advances have made it possible to keep people alive well beyond what was once possible, leading health care providers to focus on life-sustaining measures rather than questioning the futility of such measures and considering quality of life. In the midst of the struggle to foster dying well in a medicalized environment, acute care nurses may be challenged with shifting the focus to providing optimal end-of-life care because of lack of training, time, and resources. A remedy for the current western societal approach to medicalized dying is to look back in history to a time during the late Middle Ages, when death was an accepted part of medieval life. A literary genre called Ars Moriendi (translated "the art of dying") was written and illustrated to provide instruction on how to die well and how to care for the dying. Nurses can apply lessons from this text to fulfill the ethical obligation to practice with dignity and provide compassionate end-of-life care. These lessons include helping patients and families identify goals of care and accept finitude, encouraging the participation of loved ones at the bedside, and fostering reconciliation at the end of life.

Lived Experiences Among Critically Ill and Near-Death Survivors Relating to the COVID-19 Infection: A Phenomenological Study

INTRODUCTION

The COVID-19 pandemic has resulted in severe illnesses worldwide. Around 655.5 million cases were having been confirmed, including 6.6 million deaths. The extreme cases experienced near death in the intensive care unit (ICU). This study explored the survivors' experience of being near death while critically ill with the infection.

METHODOLOGY

A descriptive phenomenological study was employed. Data were collected through in-depth interviews with 14 participants from Northeastern Thailand. Content analysis was applied by using Creswell's strategy.

RESULTS

Four themes emerged: (a) anxiety and fear of dying alone, (b) environmental chaos, (c) using Thai Buddhist teaching in coping, and (d) returning from the brink of death. Moreover, the patients felt great gratitude and were grateful to the health care team.

DISCUSSION

Traumas experienced by patients in the ICU included physical and psychological distress, coping strategies, and an understanding of cultural awareness.

CONCLUSION

Psychological and culturally congruent care should be implemented for patients in the ICU.

Lived Experiences of Critically Ill COVID-19 Patients About Death and Dying: A Descriptive Phenomenology

Thinking about death is one of the most common problems of critically ill patients with COVID-19 in ICUs. Therefore, this study aims to explore the experiences of critically ill patients with COVID-19 about death and dying. This is a descriptive phenomenology approach. Participants in this study had 12 participants who were purposefully selected. The data collection method was semi-structured through interviews. Data were analyzed based on Colaizzi's approach. Data analysis generated two main themes, including personal, and non-personal; challenge thinking about death, and eight sub-themes. Thinking about the death of critically ill COVID-19 patients is a significant challenge that affects the patient's health and prolongs the treatment process. Therefore, it should be careful in the patient's treatment and care program.

Effects of family dignity interventions combined with standard palliative care on family adaptability, cohesion, and anticipatory grief in adult advanced cancer survivors and their family caregivers: A randomized controlled trial

Background

Family involvement and comfort are equally important in palliative care. Dignity undertook a new meaning and novel challenges as a result of restrictions on visits and companionship during the pandemic. Family-centered family dignity interventions have been shown to be effective in increasing patients' sense of dignity, increasing levels of hope, and reducing psychological distress; however, the effectiveness in enhancing family adaptability and intimacy in the survivor-caregiver binary and reducing expected grief have been inconclusive.

Objectives

The primary objective of this study was to assess the efficacy of family dignity interventions on family adaptability and cohesion. The secondary objective was to explore the effects of the interventions on anticipatory grief and psychological distress, and the lasting effect 1 month after the intervention.

Design

A single-blinded, two-arm parallel group, randomized controlled trial was conducted in China.

Settings

and methods: Ninety-eight dyads who met the inclusion criteria were randomly assigned to the family dignity intervention (n = 51) or standard palliative care group (n = 47) between June and August 2022. Study outcomes were measured at baseline, immediately post-intervention, and at the 1-month follow-up post-intervention evaluation. Data were analyzed using the Kolmogorov-Smirnov test, chi-square test, Fisher's exact test, independent sample t-test, Wilcoxon rank-sum test, and generalized estimation equations. The Intention-To-Treat analysis was performed for all available data.

Results

In comparison to the control group, significant improvements in family adaptability and cohesion and anticipatory grief over post-intervention and 1-month follow-up were demonstrated among the patients in the intervention group. The intervention group of caregivers had significant improvement in anticipatory grief at post-intervention and 1-month follow-up. The level of psychological distress was significantly lower in the intervention group than the control group (p < 0.05) at 1-month follow-up but the differences were not statistically significant at post-intervention. All outcomes showed clear differences from baseline after the intervention and at the 1-month follow-up evaluation but not between post-intervention and at the 1-month follow-up evaluation.

Conclusion

This study further verifies the actual effect of family dignity intervention program through randomized controlled trials, and provides a reference for improving the family relationship between advanced cancer patients and their family caregivers, and improving their mental health. The addition of family dignity intervention to standard palliative care greatly increased the adaptability and cohesion between survivors and their families, lessened the anticipatory grief of the survivor-caregiver pair, and relieved caregivers' anxiety and despair. We did not detect a statistically significant difference between post-intervention and the 1-month follow-up evaluation, suggesting that the intervention may have a durable impact at least 1 month.

Challenges for palliative care in times of COVID-19: a scoping review

Introduction

Many of the essential practices in palliative care (PC) had to be adapted to the COVID-19 pandemic. This global spread of the infectious respiratory disease, caused by SARS-CoV-2, created unprecedented obstacles. The aim of this research was to comprehensively assess the experiences and perceptions of healthcare professionals, individuals, and families in palliative and end-of-life situations during the COVID-19 pandemic.

Methods

A scoping review was conducted using the databases CINAHL Complete, MEDLINE, Scopus, SciELO, Cochrane Central Register of Controlled Trials, Psychology and Behavioral Sciences, MEDIClatina, and Portugal's Open Access Scientific Repository. The review followed the JBI® methodological approach for scoping reviews.

Results

Out of the initially identified 999 articles, 22 studies were included for analysis. The deprivation of relationships due to the safety protocols required to control the spread of COVID-19 was a universally perceived experience by healthcare professionals, individuals in PC, and their families. Social isolation, with significant psychological impact, including depersonalization and despair, was among the most frequently reported experiences by individuals in palliative situation. Despite healthcare professionals' efforts to mitigate the lack of relationships, the families of these individuals emphasized the irreplaceability of in-person bedside contact.

Systematic review registration

https://osf.io/xmpf2/.

How to Manage the Suffering of the Patient and the Family in the Final Stage of Life: A Qualitative Study

BACKGROUND

The end of life and death have changed from being issues managed within the family, assumed as part of life, to occur within health institutions for the majority of patients. The amount of patients dying at home has decreased, and the roles of families and communities in death and dying have become involuted, threatening related traditions and knowledge. As a result, a need to promote the end of life at home in this new self-serving society has arisen. In that context, the main objective of this study was to find out what patients and their families need during the end-of-life process in order to feel effectively accompanied at this time.

METHODS

With that objective, a descriptive qualitative study was conducted via the content analysis of data from semi-structured interviews and focus groups. This research adhered to the COREQ guidelines. The sample consisted of 36 informants selected via intentional sampling of family members and patients integrated into the Comprehensive Palliative Care Process (PAI Paliativos).

RESULTS

The results suggest the existence of several common needs such as communication and presence, including the conspiracy of silence as an important factor generating suffering for both. However, there are specific needs such as autonomy, dignity, and respect for patients, which must be taken into account.

CONCLUSIONS

The results of this study will allow us to establish intervention strategies for effective accompaniment of patients' family members at the end of life and the avoidance of ethnocentrism in this process. This study was retrospectively registered with the (nursrep-1194226) on the (21 April 2023).

Nobody Should Die Alone. Loneliness and a Dignified Death During the COVID-19 Pandemic

During the direst months of the COVID-19 pandemic, thousands of people died alone. This study analyzes these deaths, which occurred without the presence of loved ones, and seeks to a) examine the significance for relatives, as well as professionals, of dying alone, b) determine if these solitary deaths can be considered dignified, or good deaths, and c) evaluate if the treatment of the cadavers and the funeral rites transpired with the desired dignity and sensitivity. The study was carried out in the autonomous community of Madrid using a qualitative, phenomenological, and interpretative approach through in-depth interviews of 49 informants, professionals and relatives. Interviews were conducted between July and November of 2020, followed by an interpretive, categorical, qualitative analysis. Among the key findings are that during the most critical months, deaths lacked the desired dignity, even though the involved professionals did their best to accompany and dignify the deaths.

Nurses' bereavement experiences of a deceased colleague due to COVID-19: A phenomenological study

AIM

Healthcare workers have little time to mourn due to the intensification of the COVID-19 pandemic. Although grief is a normal part of life and death, the circumstances surrounding the death can affect the grieving process. So far, the nurses' experience in mourn for a deceased colleague in the COVID-19 pandemic has not been determined. Identifying these experiences can provide opportunities to formulate appropriate strategies to functionally adapt to death and promote mental health and well-being during this crisis. This study aimed to understand the nurses' experiences in mourning for a deceased colleague due to COVID-19.

DESIGN

This was an interpretive phenomenological study.

METHOD

Participants included 10 nurses with the bereavement experience following the death of a colleague due to COVID-19, who were selected through purposive sampling, and the data were collected through in-depth and semi-structured interviews and analysed using Diekelmann et al.'s (1989) approach.

RESULTS

The nurses' bereavement experiences were in the form of eight themes: disbelief and amazement, acceptance with grief, lasting sadness, unsung laments, bringing back memories, impulse to leave the service, a professional myth and holy death. For nurses, mourning for the death of a colleague due to COVID-19 is like a lasting sadness that begins with disbelief and amazement and changes to acceptance with sadness. From the fellow nurses' point of view, this type of death was perceived as a holy death, which along with countless unsung laments and memories brought to us the association of a professional legend, and that such a fate would be inevitable for us as well, it was a push to leave the service.

PUBLIC CONTRIBUTION

Crisis managers and policymakers need to add protocols and training programs for resilience skills and healthy mourning.

Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection

COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.

Investigating the level of respect for human dignity and its related factors in providing care for the elderly with COVID-19 in shahid Beheshti Hospital, Kashan, 2021

BACKGROUND

Patients' dignity includes the feelings of being valuable, maintaining their respect, and respecting their physical and spiritual privacy. Coronavirus disease of 2019 (COVID-19) is one of the life-threatening diseases that affect the dignity of the elderly. Therefore, the aim of this study was to investigate the level of respect for human dignity and its related factors in providing care for the elderly with COVID-19 in Shahid Beheshti Hospital in Kashan, 2021.

MATERIALS AND METHODS

This cross-sectional study investigated 250 nurses caring for the elderly with COVID-19 and 300 elderly with COVID-19 in Shahid Beheshti Hospital of Kashan in 2021. A sampling of the elderly with COVID-19 was performed continuously based on the inclusion criteria and sampling of nurses by census method. The research tools included the questionnaire on background variables of nurses and the elderly, the questionnaire on respect for human dignity from the perspective of nurse and patient, and the job stress questionnaire. Then, the results were analyzed using Pearson's correlation coefficient tests, t-tests, and multiple regression in SPSS 21 software.

RESULTS

Based on the results, the mean and standard deviation of patient dignity was 132.13 ± 71.52 and 129.14 ± 06.44 from the perspective of the nurses and the elderly, respectively. The results revealed that the level of respect for human dignity from the nurses' perspective was significantly related to gender and job stress (P < 0.05). Moreover, a significant relationship was found between the human dignity score from the elderly's perspective and the elderly's marital status and education (P < 0.05). According to the results of regression, the variables of nurses' gender and job stress explained about 8.7% of the variance of the patient's dignity observed by the nurses (Adjusted R-Square = 0.087). Finally, the variables of marriage and education of the elderly explained about 4% of the variance of their dignity observed by the nurses (Adjusted R-Square = 0.040).

CONCLUSION

The results showed that with the increase of job stress in female nurses, their human dignity toward the patient decreases. Elderly people who are married and have a high school diploma have a better understanding of respect for human dignity. Since respect for human dignity is important from the point of view of nurses and the elderly, it is suggested to teach nurses how to respect patient dignity.

The impact of COVID-19 on the experiences of patients and their family caregivers with medical assistance in dying in hospital

BACKGROUND

The COVID-19 pandemic and its containment measures have drastically impacted end-of-life and grief experiences globally, including those related to medical assistance in dying (MAiD). No known qualitative studies to date have examined the MAiD experience during the pandemic. This qualitative study aimed to understand how the pandemic impacted the MAiD experience in hospital of persons requesting MAiD (patients) and their loved ones (caregivers) in Canada.

METHODS

Semi-structured interviews were conducted with patients who requested MAiD and their caregivers between April 2020 and May 2021. Participants were recruited during the first year of the pandemic from the University Health Network and Sunnybrook Health Sciences Centre in Toronto, Canada. Patients and caregivers were interviewed about their experience following the MAiD request. Six months following patient death, bereaved caregivers were interviewed to explore their bereavement experience. Interviews were audio-recorded, transcribed verbatim, and de-identified. Transcripts were analyzed using reflexive thematic analysis.

RESULTS

Interviews were conducted with 7 patients (mean [SD] age, 73 [12] years; 5 [63%] women) and 23 caregivers (mean [SD] age, 59 [11] years; 14 [61%] women). Fourteen caregivers were interviewed at the time of MAiD request and 13 bereaved caregivers were interviewed post-MAiD. Four themes were generated with respect to the impact of COVID-19 and its containment measures on the MAiD experience in hospital: (1) accelerating the MAiD decision; (2) compromising family understanding and coping; (3) disrupting MAiD delivery; and (4) appreciating rule flexibility.

CONCLUSIONS

Findings highlight the tension between respecting pandemic restrictions and prioritizing control over the dying circumstances central to MAiD, and the resulting impact on patient and family suffering. There is a need for healthcare institutions to recognize the relational dimensions of the MAiD experience, particularly in the isolating context of the pandemic. Findings may inform strategies to better support those requesting MAiD and their families during the pandemic and beyond.

"The communication I had with him back then is still stuck in my mind." Bereaved families of cancer patients' experiences for end-of-life communication

PURPOSE

Communication with family members is important to end-of-life care for patients with cancer. It is an interactive engagement between terminally-ill cancer patients and their families through which they expand their mutual understanding to cope with losses and find meaning in death. This study aimed to describe the experiences of end-of-life communication between patients with cancer and their family members in South Korea.

METHODS

This is a qualitative descriptive study using in-depth semi-structured interviews. Ten bereaved family members with end-of-life communication experience with terminal cancer patients were recruited through purposive sampling. Data were analyzed using qualitative content analysis.

RESULTS

A total of 29 constructed meanings, 11 sub-categories, and the following 3 categories were derived: "Offering a space for patients to reminisce and reflect," "Building a bond," and "Reflections on what we need." End-of-life communication primarily centered on the patients, with families struggling to share their stories with them. Although the families coped well, they also regretted the lack of meaningful communication with the patients, indicating a need for support to facilitate effective end-of-life communication.

CONCLUSION

The study highlighted concrete communication for finding meaning at the end-of-life for cancer patients and their families. We found that the families have the potential to communicate appropriately to cope with the patients' end-of-life. Nevertheless, end-of-life presents a unique challenge in which families require adequate support. Given the increasing number of patients and families dealing with end-of-life care in hospitals, healthcare providers should be mindful of their needs and help them cope effectively.

Dignity at stake - relatives' experiences of influencing dignified care in nursing homes

BACKGROUND

Dignity, in the care of older nursing home residents, has been an increasingly part of the public discourse the recent years. Despite a growing body of knowledge about dignity and indignity in nursing homes, we have less knowledge of how relatives experience their role in this context. This study is a follow-up to a previous study in nursing homes, which gave rise to concern about the relatives' descriptions of residents' dignity. The aim of this current study is to critically discuss relatives' experiences of influencing the dignified care of residents of nursing homes.

METHODS

Methodologically, the study is informed by a critical hermeneutic stance, where the analysis is guided by a qualitative interpretive approach and a humanizing framework. This is a secondary analysis that includes data from five semi-structured focus groups from a previous study. The participants were 18 relatives of 16 residents living in two nursing homes in rural northern Norway.

RESULTS

The main theme in this study, preventing missed care when dignity is at stake, is identified when relatives of nursing homes experience that they are able to influence dignified care by (a) pinpointing to prevent missed care and (b) compensating when dignity is threatened.

CONCLUSIONS

Despite their stated good intentions to safeguard dignity, relatives of nursing homes experience being alienated in their attempts to change what they describe as undignified and unacceptable practice into dignified care. The relatives' observations of dignity and indignity are, contrary to what national and international regulations require, not mapped and/or used in any form of systematic quality improvement work. This indicates that knowledge-based practice in nursing homes, including the active application of user and relative knowledge, has untapped potential to contribute to quality improvement towards dignified care.

Social isolation at the end of life: A case report of one person's journey navigating the medical landscape during the COVID-19 pandemic

BACKGROUND

In addition to physical symptom burden, psychological suffering at end of life (EOL) is quite pervasive. As such, the interdisciplinary team in our Palliative and Supportive Care Unit strives to provide quality care sensitive to the physical and psychosocial needs of patients. Involving and allowing for the presence of family members is one way in which we afford our patients some additional comfort. Unfortunately, the current pandemic has placed limitations on this rather fundamental need for both patients and their family members. Here, we present a case illustrating the effects of visitor restrictions/isolation due to COVID-19 on the suffering of a patient at the EOL.

CASE DESCRIPTION

A male in his 20s with a refractory hematologic malignancy decided to pursue a comfort-based approach to care after a rapid clinical deterioration. Due to visitor restrictions, he had to face this decision with limited support at the bedside, which caused significant distress. He was forced to choose among several immediate family members who would be at his side through his hospitalization, to be his advocate, at times his voice, his confidant, and the person to relay all information to those on the outside. He expressed a wish to be married before he died, which occurred in our palliative care unit. This life goal was one we would normally encourage those he loved to gather around him, but this was not possible. He passed peacefully two days after he was married.

CONCLUSION

Although social limitations are necessary to help provide safety to the patients and staff in a hospital, they can have a direct impact on the suffering of patients and families at the EOL. Helping to maintain dignity, reflect on their life, and resolve any conflicts in the presence of family members is a benchmark for providing quality palliative care. Being barred from visitation due to isolation, threatens this care and lays the foundation for complicated grief among family members. Further research is needed to help balance the needs of those at the EOL with public safety. One such measure to help ease distress is to allow for more virtual visitation through electronic measures.

Same storm, different boat: The global impact of COVID-19 on palliative care

OBJECTIVE

The COVID-19 pandemic has had a complex and profound impact on the provision of palliative care globally. To support learning from palliative care providers and researchers worldwide, the Education Subcommittee of International Psycho-Oncology Society (IPOS) Palliative Care Special Interest Group developed a webinar with presentations by and discussion with eight international palliative care leaders.

METHODS

Presentations were content rich; the speakers used both quantitative (e.g., sharing recent statistical findings) and qualitative (e.g., narrative storytelling, anecdotal experiences) approaches to portray the effect of COVID-19 in their region. Subsequent to the webinar, the committee collectively identified five themes conveyed by the presenters through consensus.

RESULTS

The themes included: (1) altered accessibility to palliative care, with socio-economic status impacting virtual health availability; (2) reduced opportunities to preserve dignity, as survival has been prioritized over preserving the humanity of patients and their loved ones; (3) complicated grief and bereavement arising from social distancing requirements; (4) greater awareness of the importance of sustaining health provider well-being; and (5) the development of valuable innovations across nations, institutions, disciplines, and communities.

CONCLUSIONS

Overall, the webinar facilitated valuable connection for global learning and identified opportunities for research and clinical interventions. In an ongoing crisis that has exacerbated isolation, we will need to continue to learn and lean on one another as a global community to navigate ongoing challenges of the COVID-19 pandemic.

An Ethical Framework for Visitation of Inpatients Receiving Palliative Care in the COVID-19 Context

Human connection is universally important, particularly in the context of serious illness and at the end of life. The presence of close family and friends has many benefits when death is close. Hospital visitation restrictions during the Coronavirus (COVID-19) pandemic therefore warrant careful consideration to ensure equity, proportionality, and the minimization of harm. The Australian and New Zealand Society for Palliative Medicine COVID-19 Special Interest Group utilized the relevant ethical and public health principles, together with the existing disease outbreak literature and evolving COVID-19 knowledge, to generate a practical framework of visiting restrictions for inpatients receiving palliative and end-of-life care. Expert advice from an Infectious Diseases physician ensured relevance to community transmission dynamics. Three graded levels of visitor restrictions for inpatient settings are proposed, defining an appropriate level of minimum access. These depend upon the level of community transmission of COVID-19, the demand on health services, the potential COVID-19 status of the patient and visitors, and the imminence of the patient's death. This framework represents a cohesive, considered, proportionate, and ethically robust approach to improve equity and consistency for inpatients receiving palliative care during the COVID-19 pandemic and may serve as a template for future disease outbreaks.

Impact of COVID-19 and other infectious conditions requiring isolation on the provision of and adaptations to fundamental nursing care in hospital in terms of overall patient experience, care quality, functional ability, and treatment outcomes: systematic review

AIM

This systematic review identifies, appraises and synthesizes the evidence on the provision of fundamental nursing care to hospitalized patients with a highly infectious virus and the effectiveness of adaptations to overcome barriers to care.

DESIGN

Systematic review.

DATA SOURCES

In July 2020, we searched Medline, PsycINFO (OvidSP), CINAHL (EBSCOhost), BNI (ProQuest), WHO COVID-19 Database (https://search.bvsalud.org/) MedRxiv (https://www.medrxiv.org/), bioRxiv (https://www.biorxiv.org/) and also Google Scholar, TRIP database and NICE Evidence, forwards citation searching and reference checking of included papers, from 2016 onwards.

REVIEW METHODS

We included quantitative and qualitative research reporting (i) the views, perceptions and experiences of patients who have received fundamental nursing care whilst in hospital with COVID-19, MERS, SARS, H1N1 or EVD or (ii) the views, perceptions and experiences of professional nurses and non-professionally registered care workers who have provided that care. We included review articles, commentaries, protocols and guidance documents. One reviewer performed data extraction and quality appraisal and was checked by another person.

RESULTS

Of 3086 references, we included 64 articles; 19 empirical research and 45 review articles, commentaries, protocols and guidance documents spanning five pandemics. Four main themes (and 11 sub-themes) were identified. Barriers to delivering fundamental care were wearing personal protective equipment, adequate staffing, infection control procedures and emotional challenges of care. These barriers were addressed by multiple adaptations to communication, organization of care, staff support and leadership.

CONCLUSION

To prepare for continuation of the COVID-19 pandemic and future pandemics, evaluative studies of adaptations to fundamental healthcare delivery must be prioritized to enable evidence-based care to be provided in future.

IMPACT

Our review identifies the barriers nurses experience in providing fundamental care during a pandemic, highlights potential adaptations that address barriers and ensure positive healthcare experiences and draws attention to the need for evaluative research on fundamental care practices during pandemics.

The Impact of COVID-19 on Palliative Care: Perspective of Healthcare Professionals

The COVID-19 pandemic has negatively impacted the provision of Palliative Care (PC), challenging the teams aiming to provide adequate care.

This is a qualitative study that intends to know, from the perspective of health professionals of a Palliative Care Unit (PCU), the main challenges in providing PC during a pandemic and describes the strategies to be adopted to solve the identified difficulties. We utilized the content analysis, according to Bardin, for data analysis of written narratives of health professionals from a PCU (n=14). In the analysis of the difficulties in providing PC, from the perspective of health professionals, were identified five themes: 1) Altered relationship between healthcare professional and patients, 2) altered relationship between healthcare professional and family, 3) altered communication with patients and their family, 4) altered working dynamic within the PCU, and 5) altered use of healthcare resources. Concerning the strategies to be implemented, the health professionals identified two themes: 1) Strategies to implement between the patient and family members and 2) strategies to implement for the healthcare professionals.

The provision of PC is affected by changes in the relationship between the health professional and the patient/caregiver or family, in communication with the patient/caregiver or family, and the use of health resources. In an attempt to lessen the impact of these changes, participants identified strategies to improve PC delivery in these circumstances. During this pandemic, it is imperative to implement rigorous strategies for managing specialized human resources. Physical distance and personal protective equipment are barriers to communication and emotional support, which is essential in PC and this barrier is further accentuated by the required physical distance from family members and caregivers. PC´s main aim continues to be the mitigation of suffering.

End-of-Life Care During the Coronavirus Disease 2019 Pandemic: The 3 Wishes Program

Supplemental Digital Content is available in the text.

Patient- and family-centered end-of-life care can be difficult to achieve in light of visitation restrictions and infection-prevention measures. We evaluated how the 3 Wishes Program evolved to allow continued provision of compassionate end-of-life care for critically ill patients during the coronavirus disease 2019 pandemic.

Perceptions and Experiences of the COVID-19 Pandemic amongst Frontline Nurses and Their Relatives in France in Six Paradoxes: A Qualitative Study

Due to their frontline position to fight the coronavirus disease 2019 (COVID-19), the professional and personal life of nurses was severely disrupted. To understand and describe their lived experiences and perceptions during the pandemic's first wave in France, we interviewed 49 nurses, including 16 nursing students, and 48 of their family members from June to July 2020. Using a purposeful sampling, the semi-structured interviews were scripted according to Abric's method with probing questions. The interview analysis led to the identification of six paradoxical perceptions concerning the pandemic's consequences: the Silence Paradox, the Hero Paradox, the Workforce Paradox, the Learning Paradox, the Symbolic Exchange Paradox, and the Uncertainty Paradox. However, despite different experiences, the nurses perceived their frontline position both as a burden jeopardizing their safety and well-being and as a spotlight of nurses' tough working conditions. Indeed, because they were in the frontline position, nurses and nursing students were psychologically vulnerable, even more so when they felt alone and inadequately protected. Besides, their families were vulnerable too, as they were also exposed to the consequences of the nurses' frontline engagement. Thus, to preserve their safety and well-being, institutions should also provide them with better organizational support and inclusive leadership, without neglecting their families.

Practical Considerations in Providing End-of-Life Care for Dying Patients and Their Family in the Era of COVID-19

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality end-of-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients' symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to post-bereavement problems in the COVID-19 era. Establishing a system of screening high-risk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one's death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Navigating the terrain of moral distress: Experiences of pediatric end-of-life care and bereavement during COVID-19

OBJECTIVE

Parents of seriously ill children worry about their vulnerable child contracting COVID-19, whether their child's palliative care providers will be able to continue to provide the same quality of care to their child, and who can be with the child to provide comfort. For providers, shifts in healthcare provision, communication formats, and support offerings for families facing distress or loss during the pandemic may promote providers' moral distress. This study aimed to define the ways that the COVID-19 pandemic has impacted end-of-life care and approach to bereavement care in pediatric palliative care (PPC).

METHOD

The Palliative Assessment of Needed DEvelopments and Modifications In the Era of Coronavirus (PANDEMIC) survey was developed to learn about the PPC experience during COVID-19 in the United States. The survey was posted with permission on seven nationally focused Listservs.

RESULTS

A total of 207 PPC team members from 80 cities within 39 states and the District of Columbia participated. In the majority of hospitals, admitted pediatric patients were only allowed one parent as a visitor with the exception of both parents or nuclear family at end of life. Creative alternatives to grief support and traditional funeral services were described. The high incidence of respondents' depicted moral distress was often focused on an inability to provide a desired level of care due to existing rules and policies and bearing witness to patient and family suffering enhanced by the pandemic.

SIGNIFICANCE OF RESULTS

The COVID-19 pandemic has had a profound impact on the provision of end-of-life care and bereavement for children, family caregivers, and PPC providers. Our results identify tangible limitations of restricted personal contact and the pain of watching families stumble through a stunted grieving process. It is imperative that we find solutions for future global challenges and to foster solidarity in PPC.

Clinician Perspectives on Caring for Dying Patients During the Pandemic : A Mixed-Methods Study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors, and staff.

OBJECTIVE

To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic.

DESIGN

Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520).

SETTING

3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020.

PARTICIPANTS

45 dying patients, 45 family members, and 45 clinicians.

INTERVENTION

During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and "what matters most," eliciting wishes, and implementing acts of compassion.

MEASUREMENTS

Themes from semistructured clinician interviews that were summarized with representative quotations.

RESULTS

Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences. During hospitalization, family visits inside or outside the patient's room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to "fill the gap" of absent family and by initiating new and established ways to connect patients and relatives.

LIMITATION

Absence of clinician symptom or wellness metrics; a single-center design.

CONCLUSION

Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research and Canadian Critical Care Trials Group Research Coordinator Fund.