Project Respect: experiences of seriously ill LGBTQ+ patients and partners with their health care providers

Hidden From Sight-From the Closet to the Paywall: A Rapid Evaluation of Restricted and Monetized Access to LGBTQ+ Inclusive Palliative, End-of-Life, and Bereavement Care Research

INTRODUCTION

LGBTQ+ people experience higher burdens of life-limiting illnesses, poorer health outcomes, and multilevel barriers to accessing palliative, end-of-life, and bereavement care. High quality evidence is needed to inform interventions to address these inequities, and inform inclusive practices and policies. Despite global initiatives to improve availability of peer-reviewed journal articles, the minority of research is open access (OA). We aimed to evaluate accessibility of literature related to LGBTQ+ inclusive palliative, end-of-life, and bereavement care.

METHODS

A rapid review of the evidence regarding LGBTQ+ inclusive palliative, end-of-life, and bereavement care was conducted; OA status of identified articles was assessed. Articles from three published systematic reviews were included (2012, 2016, and 2020). Review articles were updated using the original search and inclusion/exclusion strategies.

RESULTS

66 articles related to LGBTQ+ inclusive palliative, end-of-life and bereavement care were identified between 1990-2022. Of these, only 21% (n=14) were OA. Of the OA articles, 79% were published between 2017 and 2022, and 50% were published between 2020-2022, reflecting more recent shifts towards OA publishing.

DISCUSSION

Health and social care professionals and policy makers rely on access to high quality evidence to inform their work. Failing to make articles related to the needs of LGBTQ+ people and populations OA risks further marginalisation and worsened inequities. Innovative journal policies and funding are needed to enable access, particularly for research that foregrounds the needs of marginalised communities. Where articles are currently behind paywalls, there is a need for accessible summaries or policy briefs to inform inclusive policy and practice.

My Partner Is My Family: Engaging and Advocating for Lesbian, Gay, Bisexual, Transgender, Queer+ Patients in Goals of Care Conversations

In goals of care conversations and through the care trajectory, to avoid insensitive or discriminatory care, it is vital clinicians recognize lesbian, gay, bisexual, transgender, queer+ patients' values and wishes. In clinical settings, implicit bias operating within unconscious awareness may challenge the commitment to equitable care, negatively affecting patient outcomes. In this composite case, during a conversation with a social worker/nurse team, a cisgender woman repeatedly expressed her wishes for her female partner to be her decision maker instead of her biological family. The conversation stalled during the patient's attempts to identify her partner as her most valued and trusted person. Interviewer follow-up responses based on motivational interviewing techniques, which do not include strategies for lesbian, gay, bisexual, transgender, queer+ interactions, inaccurately reflected the patient's needs. Two ethical issues emerged, (1) autonomy and (2) beneficence. Clinicians should approach all patients using nongendered language, and allow patients to self-identify and decide which people are in their support system. Lack of inclusivity training has significant potential to affect the patient experience and decrease clinician/patient trust. Clinicians should not assume the decision maker is a cisgender, heterosexual partner or a biological family member. When patients speak about their partners, it is imperative clinicians use the patient's language and not avoid or redirect responses.

Communicating with LGBTQ+ persons at end of life: A case-based analysis of interdisciplinary palliative clinician perspectives

OBJECTIVE

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) persons with serious illness and their families often experience end-of-life (EOL) care disparities, such as homophobia and transphobia, disrespect and mistreatment, and exclusion of significant others or life partners. The aim of the study was to explore interdisciplinary clinicians' communication knowledge and priorities using a case of a gay man at EOL and his same-sex, cisgender spouse.

METHODS

Interdisciplinary clinicians (n = 150) who participated in a national 3-day communication training program, rooted in Adult Learning Theory and supported by the National Cancer Institute, responded to open-ended questions about a composite case study emphasizing diversity challenges relevant to LGBTQ + communities in the EOL context. A thematic analysis of responses using an iterative, inductive approach was conducted until saturation was reached.

RESULTS

Participants from nursing (48%), social work (35%) and chaplaincy (17%) responded to the survey. Five themes emerged: 1) provision of patient-centered care; 2) legal and ethical factors inform care and decision making; 3) considerations of same-sex spouse or couple context; 4) dynamics and role of family of origin; and 5) elements of inclusive clinical care.

CONCLUSIONS

LGBTQ + inclusive communication training is essential for all palliative clinicians to deliver culturally safe care. Our findings have implications for identifying unconscious bias, addressing discriminatory care, filling clinician knowledge gaps, and informing educational interventions to support LGBTQ + inclusion. Future research must focus on micro- and macro-level communication issues that shape the quality of palliative and EOL care for patients and chosen family members.