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Miller EM, Porter JE, Barbagallo MS. The Effects of the Ward Environment and Language in Palliative Care: A Qualitative Exploratory Study of Victorian Nurses' Perspectives. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2023; 16:146-158. [PMID: 37265375 PMCID: PMC10621022 DOI: 10.1177/19375867231177299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The current study aimed to explore regional nurses' perspectives of how bad news is delivered and the physical, natural, social, and symbolic environments where these conversations occur. BACKGROUND In regional hospitals within Victoria, Australia, palliative and end-of-life patients are cared for in acute wards that are often busy, noisy, and do not have a palliative psychosocial focus. On the other hand, Palliative Care Units (PCUs) have more home-like dedicated spaces, yet nearly all these facilities are in metropolitan areas. Diagnostic/prognostic (bad news) conversations about life-limiting illnesses often occur at the bedside in both environments. METHOD Nurses providing palliative or end-of-life care in regional or metropolitan Victorian hospital inpatient wards were invited to interview and recruited through social media and snowballing. Six semi-structured, audio-recorded online interviews were conducted between March and May 2022, and themes were developed using reflexive thematic analysis. RESULTS Semi-structured online interviews were conducted with six female, registered nurses, four of whom worked in regional Victorian hospitals and two in metropolitan PCUs as Nurse Unit Managers. Three central themes were developed: "conducting family meetings," "palliative care practice," and "the environment matters." CONCLUSIONS A therapeutic environment for palliative patients and their families consists of home-like ambience and aesthetics and a psychosocial environment created by staff who can provide holistic palliative care. Holistic palliative care requires mentoring and mirroring of expert practice to increase the expertise and capacity of the palliative care workforce in acute general hospital wards.
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Affiliation(s)
- Elizabeth M. Miller
- Collaborative Evaluation and Research Group (CERG), Federation University Australia, Churchill, Victoria, Australia
| | - Joanne E. Porter
- Collaborative Evaluation and Research Group (CERG), Federation University Australia, Churchill, Victoria, Australia
| | - Michael S. Barbagallo
- Institute of Health and Wellbeing, Federation University Australia, Churchill, Victoria, Australia
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Bloomer MJ, Yuen E, Williams R, Bouchoucha S, Poon P, Runacres F, Mooney C, Hutchinson AM. Perspectives of family-centred care at the end of life during the COVID-19 pandemic: A qualitative descriptive study. J Clin Nurs 2023. [PMID: 36653924 DOI: 10.1111/jocn.16627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/25/2022] [Accepted: 12/31/2022] [Indexed: 01/20/2023]
Abstract
AIM To explore nurses' and family members' perspectives of family care at the end of life, during restricted visitation associated with the COVID-19 pandemic. BACKGROUND To minimise the transmission of COVID-19, stringent infection prevention and control measures resulted in restricted hospital access for non-essential workers and visitors, creating challenges for the provision of family-centred care at the end of life. DESIGN Qualitative descriptive approach based on naturalistic inquiry. METHODS At a large public hospital in Melbourne, Australia, individual semi-structured interviews were undertaken with 15 registered nurses who cared for patients who died during restricted visitation associated with the COVID-19 pandemic, and 21 bereaved family members. COREQ guidelines informed analysis and reporting. RESULTS Five themes developed from the data: (i) impact of visitor restrictions, which describes uncertain, ambiguous and arbitrary rules, onerous and inconsistent requirements; (ii) nurse-family communication; (iii) family-centred care and interrupted connections; (iv) well-being and negative emotions; and (v) suggestions for a better way, such as moving away from the black and whiteness of the rules, prioritising communication, compassion and advocacy. CONCLUSIONS Negative consequences for communication and the patient-family connection at the end of life were felt deeply. The evolving COVID-19 rules that were frequently revised and applied at short notice, and the subsequent consequences for clinical practices and care were felt deeply. RELEVANCE TO CLINICAL PRACTICE Technology-facilitated communication, innovation and increased resources must be prioritised to overcome the challenges described in this study. A family-centred approach to care and emphasising the patient-family connection at the end of life is fundamental to minimising trauma and distress associated with future public health emergencies. PATIENT OR PUBLIC CONTRIBUTION Bereaved family members contributed their first-hand experience. Members of the health service's patient experience team ensured the research was conducted in accordance with health service guidelines for patient and public contribution.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia.,Intensive Care Unit, Princess Alexandra Hospital, Queensland Health, Woolloongabba, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.,School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Eva Yuen
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Ruth Williams
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Monash Health Partnership, Monash Health, Clayton, Victoria, Australia
| | - Stephane Bouchoucha
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Peter Poon
- Supportive and Palliative Care Unit, Monash Health, Clayton, Victoria, Australia.,School of Medicine, Monash University, Clayton, Victoria, Australia
| | - Fiona Runacres
- Supportive and Palliative Care Unit, Monash Health, Clayton, Victoria, Australia.,School of Medicine, Monash University, Clayton, Victoria, Australia.,Department of Palliative Care, Calvary Health Care Bethlehem, Parkdale, Victoria, Australia
| | - Christine Mooney
- Supportive and Palliative Care Unit, Monash Health, Clayton, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia.,Centre for Quality and Patient Safety Research - Barwon Health Partnership, Barwon Health, Geelong, Victoria, Australia
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Bloomer MJ, Walshe C. Smiles behind the masks: A systematic review and narrative synthesis exploring how family members of seriously ill or dying patients are supported during infectious disease outbreaks. Palliat Med 2021; 35:1452-1467. [PMID: 34405753 DOI: 10.1177/02692163211029515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Infection control measures during infectious disease outbreaks can have significant impacts on seriously ill and dying patients, their family, the patient-family connection, coping, grief and bereavement. AIM To explore how family members of patients who are seriously ill or who die during infectious disease outbreaks are supported and cared for during serious illness, before and after patient death and the factors that influence family presence around the time of death. DESIGN Systematic review and narrative synthesis. DATA SOURCES CINAHL, Medline, APA PsycInfo and Embase were searched from inception to June 2020. Forward and backward searching of included papers were also undertaken. Records were independently assessed against inclusion criteria. Included papers were assessed for quality, but none were excluded. FINDINGS Key findings from 14 papers include the importance of communication and information sharing, as well as new ways of using virtual communication. Restrictive visiting practices were understood, but the impact of these restrictions on family experience cannot be underestimated, causing distress and suffering. Consistent advice and information were critical, such as explaining personal protective equipment, which family found constraining and staff experienced as affecting interpersonal communication. Cultural expectations of family caregiving were challenged during infectious disease outbreaks. CONCLUSION Learning from previous infectious disease outbreaks about how family are supported can be translated to the current COVID-19 pandemic and future infectious disease outbreaks. Consistent, culturally sensitive and tailored plans should be clearly communicated to family members, including when any restrictions may be amended or additional supports provided when someone is dying.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, Geelong, Australia.,Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
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O'Brien Gufarotti J, Krakowski A. The Journey of the Purple Butterfly: A Quality Improvement Initiative. Am J Hosp Palliat Care 2021; 39:205-210. [PMID: 34056949 DOI: 10.1177/10499091211014164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Dying in the hospital is not always a good experience for patients and their families. To be more in line with evidence-based practices for healthcare workers to effectively support high quality end of life care, the project team implemented a standardized communication tool to alert interdisciplinary team members of patients on comfort care measures. METHODS Purple Butterfly was a quality improvement project that was implemented at a diverse community hospital in the urban setting. Clinical and non-clinical interdisciplinary team members participated in a pre- and post- implementation survey to assess the need for a standardized communication tool that would alert them of patients who transitioned to comfort care. RESULTS Pre-implementation, 37% of survey respondents (n = 60) reported they were always aware of the presence of a patient on comfort care measures prior to entering the room. After implementation of a standardized communication tool, 100% (n = 43) of respondents at 9 months, reported that they were always aware of the presence of a patient on comfort care measures prior to entering the room. Additionally, 9 months post-intervention 100% of respondents reported that knowing this contextual information supported them in performing their job duties in a compassionate, patient-centered fashion. CONCLUSION Implementation of a standardized communication tool increased awareness for team members, about the presence of patients on comfort care measures prior to entering the room and supported team members to perform their job duties in a compassionate, patient-centered fashion supportive of this patient population.
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Affiliation(s)
| | - Anna Krakowski
- 25066NewYork-Presbyterian Lower Manhattan Hospital, New York, NY, USA
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Bouchoucha SL, Bloomer MJ. Family-centered care during a pandemic: The hidden impact of restricting family visits. Nurs Health Sci 2021; 23:4-6. [PMID: 32533617 PMCID: PMC7323067 DOI: 10.1111/nhs.12748] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Stéphane L. Bouchoucha
- School of Nursing and MidwiferyDeakin UniversityGeelongVictoriaAustralia
- Centre for Quality and Patient Safety ResearchDeakin UniversityGeelongVictoriaAustralia
- Institute for Health TransformationDeakin UniversityGeelongVictoriaAustralia
| | - Melissa J. Bloomer
- School of Nursing and MidwiferyDeakin UniversityGeelongVictoriaAustralia
- Centre for Quality and Patient Safety ResearchDeakin UniversityGeelongVictoriaAustralia
- Institute for Health TransformationDeakin UniversityGeelongVictoriaAustralia
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Bloomer MJ, Bouchoucha S. Australian College of Critical Care Nurses and Australasian College for Infection Prevention and Control position statement on facilitating next-of-kin presence for patients dying from coronavirus disease 2019 (COVID-19) in the intensive care unit. Aust Crit Care 2021; 34:132-134. [PMID: 32826150 PMCID: PMC7365101 DOI: 10.1016/j.aucc.2020.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is challenging healthcare systems worldwide, none more so than critical and intensive care settings. Significant attention has been paid to the capacity of Australian intensive care unit (ICUs) to respond to a COVID-19 surge, particularly in relation to beds, ventilators, staffing, personal protective equipment, and unparalleled increase in deaths in ICUs associated with COVID-19 seen internationally. While death is not uncommon in critical care, the international experience demonstrates that restrictions to family presence at the end of life result in significant distress for families and clinicians. As a result, the Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control supported the development of a position statement to provide critical care nurses with specific guidance and recommendations for practice for this emerging priority area. Where possible, position statements are founded on high-quality evidence. However, the short time period since the first recognition of a cluster of pneumonia-like cases in China in January, 2020, meant that an integrative approach was required to expedite timely development of this position statement in preparation for a COVID-19 surge in Australia. This position statement is intended to provide practical guidance to critical care nurses in facilitating next-of-kin presence for patients dying from COVID-19 in the ICU.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Research Advisory Panel, Australian College of Critical Care Nurses, Surrey Hills, Victoria, 3127, Australia.
| | - Stéphane Bouchoucha
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Australasian College for Infection Prevention and Control, 228 Liverpool Street, Hobart, Tasmania, 7000, Australia
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Bloomer MJ, Bouchoucha S. Editorial: COVID-19 and what it means for end-of-life care in ICU: Balancing the priorities. Collegian 2020; 27:248-249. [PMID: 32565714 PMCID: PMC7297167 DOI: 10.1016/j.colegn.2020.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, Geelong, Australia
- Centre for Quality and Patient Safety Research, Deakin University, Australia
- Institute for Health Transformation, Deakin University, Australia
- Research Advisory Panel, Australian College of Critical Care Nurses, Australia
| | - Stephane Bouchoucha
- School of Nursing and Midwifery, Deakin University, Geelong, Australia
- Centre for Quality and Patient Safety Research, Deakin University, Australia
- Institute for Health Transformation, Deakin University, Australia
- Australasian College for Infection Prevention and Control, Australia
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Chamberlin P, Lambden J, Kozlov E, Maciejewski R, Lief L, Berlin DA, Pelissier L, Yushuvayev E, Pan CX, Prigerson HG. Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout. J Palliat Med 2019; 22:1039-1045. [PMID: 30874470 DOI: 10.1089/jpm.2018.0385] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (β = 0.55, SE = 0.12, p < 0.001), avoiding the patient (β = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (β = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.
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Affiliation(s)
- Peter Chamberlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Jason Lambden
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Elissa Kozlov
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Renee Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Lindsay Lief
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Latrice Pelissier
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Elina Yushuvayev
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Cynthia X Pan
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
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Chang WP. How social support affects the ability of clinical nursing personnel to cope with death. Appl Nurs Res 2018; 44:25-32. [DOI: 10.1016/j.apnr.2018.09.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/08/2018] [Accepted: 09/16/2018] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Intensive care units (ICUs) exist to support patients through acute illness that threatens their life. Although ICUs aim to save life, they are also a place where a significant proportion of patients die with international mortality rates ranging from 15% to 24%. AIM To explore the experience of relatives and staff of patients dying in ICU using qualitative approach. DESIGN Consecutive patients were identified who were dying in the ICU. The researcher met the families prior to the patient's death. The ICU nurse and doctor most involved were interviewed within 48 h of the death. The families were interviewed 2 weeks later. Interviewees described their experience of the patient's dying and death. Recruitment until data saturation and thematic analysis occurred concurrently. RESULTS Ten families, nurses and doctors were interviewed in relation to 10 patients. In caring for the patients who are dying in the ICU and their families, nurses practice to their satisfaction with creativity and autonomy, although concerned about continuity of care at handover. Families appreciate kindness and regular sensitive communication. Families would like more contact with the ICU doctors. Limiting access to the patient according to ICU protocol is distressing for relatives. Doctors struggle with decision making, determining prognosis and witnessing the grief of relatives. Some doctors wish to have a greater part in care of the dying patient. CONCLUSION Distress among nurses reported in the ICU literature and attributed to disenfranchisement by doctors was not evident. In contrast, some doctors struggle to practice what they value. Adherence to ICU protocols needs flexibility when a patient is dying.
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Affiliation(s)
| | - A Psirides
- Intensive Care Department, Wellington Regional Hospital, Aotearoa, New Zealand
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Slatyer S, Pienaar C, Williams AM, Proctor K, Hewitt L. Finding privacy from a public death: a qualitative exploration of how a dedicated space for end-of-life care in an acute hospital impacts on dying patients and their families. J Clin Nurs 2015; 24:2164-74. [PMID: 25940310 DOI: 10.1111/jocn.12845] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2015] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES To explore the experiences and perceptions of hospital staff caring for dying patients in a dedicated patient/family room (named Lotus Room). BACKGROUND Dying in hospital is a common outcome for people across the world. However, noise and activity in acute environments present barriers to quality end-of-life care. This is of concern because care provided to dying patients has been shown to affect both the patients and the bereaved families. DESIGN A qualitative descriptive approach was used. METHODS Semi-structured interviews were conducted with 17 multidisciplinary staff and seven families provided information through an investigator-developed instrument. RESULTS Qualitative data analysis generated three categories describing: Dying in an hospital; The Lotus Room; and the Outcomes for patients and families. The Lotus Room was seen as a large, private and, ultimately, safe space for patients and families within the public hospital environment. Family feedback supported staff perspectives that the Lotus Room facilitated family presence and communication. CONCLUSIONS The privacy afforded by the Lotus Room within this acute hospital provided benefits for the dying patients and grieving families. Improved outcomes included a peaceful death for patients, which may have assisted the family with their bereavement. RELEVANCE TO CLINICAL PRACTICE This study provides evidence of how the physical environment can address well-established barriers to quality end-of-life care in acute hospitals.
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Affiliation(s)
- Susan Slatyer
- School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.,Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Catherine Pienaar
- School of Nursing and Midwifery, Curtin University, Bentley, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Anne M Williams
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia.,Health Research, School of Health Professions, Murdoch University, Murdoch, WA, Australia
| | - Karen Proctor
- Palliative Care Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Laura Hewitt
- Palliative Care Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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