Ethical considerations for the utilization of tele-health technologies in home and hospice care by the nursing profession

A Pilot of a Telehealth-Hospice Transition Intervention for Children and Young Adults with Cancer

BACKGROUND AND AIMS

Telehealth can improve care for patients with progressive cancer enrolling in hospice. Coordinated telehealth visits (patient/family-hospital-hospice) may improve communication, satisfaction with and interdisciplinary hospice collaboration. This pilot examines the impact of three coordinated telehealth visits on these outcomes.

METHODS

This is a prospective pilot study of 0-29-year-old patients with cancer initiating hospice care between 2021-2023. Adult patients, caregivers, oncology and palliative care clinicians, hospice nurses and administrators were surveyed about feasibility and acceptability with telehealth (Technology Acceptance Model 2) after first and third telehealth visits. Hospice satisfaction (Consumer Assessment of Healthcare Providers and Systems) was completed by caregivers after visit 3 and during bereavement. Healthcare professionals completed the Assessment of Interprofessional Team Collaboration Scale II (AITCS-II). Survey responses were summarized and differences in scores were analyzed.

RESULTS

Of 40 eligible patients, 24 enrolled, 19 completed visit 1, and 13 completed visit 3. Fourteen caregivers and two adult patients completed visit 1 surveys; nine caregivers and two adult patients completed visit 3 surveys. Participants highly rated telehealth acceptability after visit 1 (Median: 4.5, IQR: 4.0-4.7) and 3 (Median: 4.4, IQR: 4.0-4.7). Hospice services were rated as highly satisfactory at visit 3 (Median: 4.0, IQR: 3.7-4.0) and during bereavement (Median: 3.7, IQR: 3.5-4.0). Healthcare professionals (n = 85 surveys) reported excellent interprofessional collaboration (Hospital clinicians median: 99/115 and hospice teams 111/115).

CONCLUSIONS

Participants found coordinated telehealth visits to be feasible, acceptable, and satisfactory. Telehealth may be utilized as an acceptable alternative to clinic visits and fosters hospital-hospice collaboration.

The tragic paradoxical effect of telemedicine on healthcare disparities- a time for redemption: a narrative review

BACKGROUND

Telemedicine has become more convenient and advantageous due to the rapid development of the internet and telecommunications. A growing number of patients are turning to telemedicine for health consultations and health-related information. Telemedicine can increase access to medical care by removing geographical and other barriers. In most nations, the COVID-19 pandemic imposed social isolation. This has accelerated the transition to telemedicine, which has become the most commonly utilized method of outpatient care in many places. Telehealth can assist resolve gaps in access to healthcare services and health outcomes, in addition to its primary function of boosting accessibility to remote health services. However, as the benefits of telemedicine become more apparent, so do the limitations of serving vulnerable groups. Some populations may lack digital literacy or internet access. Homeless persons, the elderly, and people with inadequate language skills are also affected. In such circumstances, telemedicine has the potential to exacerbate health inequities.

AIM AND METHODS

In this narrative review (using the PubMed and Google scholar database), the different benefits and drawbacks of telemedicine are discussed, both globally and in Israel, with particular focus paid to special populations and to the telehealth usage during the Covid-19 period.

FINDINGS

The contradiction and paradox of using telemedicine to address health inequities yet sometimes making them worse is highlighted. The effectiveness of telemedicine in bridging access to healthcare inequities is explored along with a number of potential solutions.

CONCLUSIONS

Policy makers should identify barriers among special populations to using telemedicine. They should initiate interventions to overcome these barriers, while adapting them to the needs of these groups.

Telemedicine in nursing homes: Insights on the social acceptance and ethical acceptability of telemedical consultations

Introduction

The increasing number of older adults in need of care, the resulting rise in demand for care services and the shortage of nursing staff are major challenges for society. In these situations, the use of telemedicine seems promising - especially in nursing homes when the focus is on rapid support in acute medical cases. However, in addition to the medical and technical potential, the acceptability and usability of the use of telemedical consultations are crucial for a sustainable implementation and acceptance. Our research aims at a holistic identification of socially and ethically relevant parameters for the evaluation of telemedical consultations in nursing homes.

Methods

Presentation of the empirical approach of an interdisciplinary cooperation that combines social and ethical research perspectives during an entire research project. Qualitative analysis of social and ethical aspects based on an interview study with care personnel (N = 14) who have experiences with telemedical consultations in nursing homes, as an example of this interdisciplinary collaboration and to show first insights.

Results

The results of the interview study show a slightly positive evaluation of the use of telemedical consultations in nursing homes. Six main categories were identified to capture and differentiate ethically and socially relevant perceived benefits and barriers (contact with physicians, general, personnel-related, residents-related, technical, and organizational aspects).

Conclusion

The study results allow initial recommendations for the implementation of telemedicine consultations in nursing homes considering socially and ethically relevant aspects. These recommendations can be used to inform medical and technical experts in the field of telemedicine. In addition, the presentation of the interdisciplinary collaboration shows that the close integration of social and ethical aspects in research enables a holistic dimension of the use of telemedicine.

Which Framework to Use? A Systematic Review of Ethical Frameworks for the Screening or Evaluation of Health Technology Innovations

Innovations permeate healthcare settings on an ever-increasing scale. Health technology innovations (HTIs) impact our perceptions and experiences of health, care, disease, etc. Because of the fast pace these HTIs are being introduced in different healthcare settings, there is a growing societal consensus that these HTIs need to be governed by ethical reflection. This paper reports a systematic review of argument-based literature which focused on articles reporting on ethical frameworks to screen or evaluate HTIs. To do this a four step methodology was followed: (1) Literature search conducted in five electronic literature databases; (2) Identification of relevant articles; (3) Development of data-extraction tool to analyze the included articles; (4) Analysis, synthesis of data and reporting of results. Fifty-seven articles were included, each reporting on a specific ethical framework. These ethical frameworks existed out of characteristics which were grouped into five common ones: (1) Motivations for development and use of frameworks; (2) Objectives of using frameworks; (3) Specific characteristics of frameworks (background context, scope, and focus); (4) Ethical approaches and concepts used in the frameworks; (5) Methods to use the frameworks. Although this multiplicity of ethical frameworks shows an increasing importance of ethically analyzing HTIs, it remains unclear what the specific role is of these analyses. An ethics of caution, on which ethical frameworks rely, guides HTIs in their design, development, implementation, without questioning their technological paradigm. An ethics of desirability questions this paradigm, without guiding HTIs. In the end, a place needs to be found in-between, to critically assess HTIs.

Promise and peril-defining ethical telehealth practice from the clinician and patient perspective: A qualitative study

OBJECTIVES

We undertook a qualitative study to examine and compare the experience of ethical principles by telehealth practitioners and patients in relation to service delivery theory. The study was conducted prior to and during the recent global increase in the use of telehealth services due to the COVID-19 pandemic.

METHODS

We conducted semi-structured interviews with 20 telehealth practitioners and patients using constructionist grounded theory methods to collect and analyse data. Twenty-five axial coded data categories were then unified and aligned through selective coding with the Beauchamp and Childress (2013) framework of biomedical ethics. The groups were then compared.

RESULTS

Thirteen categories aligned to the ethical framework were identified for practitioners and 12 for patients. Variance existed between the groups. Practitioner results were non-maleficence 4/13 or (31%), beneficence 4/13 (31%), professional-patient relationships 3/12 (22%), autonomy 1/13 (8%) and justice 1/13 (8%). Patient data results were non-maleficence 4/12 (33%), professional-patient relationships 3/12 (33%), autonomy 2/12 (18%), beneficence 1/12 (8%) and justice 1/12 (8%).

CONCLUSIONS

Ethical principles are experienced differently between telehealth practitioners and patients. These differences can impact the quality and safety of care. Practitioners feel telehealth provides better care overall than patients do. Patients felt telehealth may force a greater share of costs and burdens onto them and reduce equity. Both patients and practitioners felt telehealth can be more harmful than face-to-face service delivery when it creates new or increased risk of harms. Building sufficient trust and mutual understanding are equally important to patients as privacy and confidentiality.

Commentary: Remote assessments of gait and balance - Implications for research during and beyond Covid-19

The COVID-19 pandemic has disrupted non-essential in-person research activities that require contact with human subjects. While guidelines are being developed for ramping up human subjects research, one component of research that can be performed remotely is participant screening for lower limb function and gait impairments. In this commentary, we summarize evidence-supported clinical assessments that have potential to be conducted remotely in a safe manner, to make an initial determination of the functional mobility status of persons with neurological disorders. We present assessments that do not require complex or costly equipment, specialized software, or trained personnel to administer. We provide recommendations to implement remote functional assessments for participant recruitment and continuation of lower limb neurorehabilitation research as a rapid response to the COVID-19 pandemic and for utilization beyond the current pandemic. We also highlight critical research gaps related to feasibility and measurement characteristics of remote lower limb assessments, providing opportunities for future research to advance tele-assessment and tele-rehabilitation.

Safely and Actively Aging in Place: Older Adults' Attitudes and Intentions Toward Smart Home Technologies

As smart technology use is growing in residential environments, research on how such technologies can provide opportunities for safely and actively aging in place by integrating physical activity into daily routines and reducing sedentariness is scarce. This study investigated older adults' intentions to use and attitudes toward currently available smart home technologies that could contribute to safe and active lives in and around home. The focus was on four representative technologies: smart lighting, smart door locks, smart fire prevention devices, and smart home systems/home automation. This paper presents the results of a sequential mixed-methods study comprised of online and in-person surveys (n = 129), and a focus group of community-dwelling older adults, aged 50+ (n = 15). Ordinal regression analyses indicated that perceived usefulness consistently predicts older adults' attitudes and willingness to use smart home products. While smart fire prevention devices were viewed most favorably due to their potential safety benefits, perceived affordability significantly influenced older adults' intentions to use them in their homes. The focus group findings underscore technology skepticism, privacy concerns and return on investment as significant determinants of attitudes toward the smart design products. The study has implications of designers and manufacturers by providing insights on how to prioritize smart home technology integrations to homes.

The Value of Applying Ethical Principles in Telehealth Practices: Systematic Review

Background

As the use of technology to deliver health services is increasing rapidly and has further intensified during the COVID-19 pandemic, these initiatives may fail if ethical impacts are not fully identified and acted upon by practitioners. Ignoring the ethical impacts of information and communication technology health service delivery creates an unintended risk for patients and can lead to reduced effectiveness, noncompliance, and harm, undermining the best intentions of governments and clinicians.

Objective

Our aim was to explore how ethical considerations or impacts may be different, greater, or more variable in information and communication technology methods versus face-to-face health care delivery models, and how they may be applied in practice.

Methods

We undertook a systemic literature review to provide a critical overview of existing research into the incorporation of ethical principles into telehealth practice. Six databases were searched between March 2016 to May 2016 and again in December 2020 to provide the benefit of currency. A combination of broad terms (“ethics,” “ethical,” “health,” and “care”) with the restrictive terms of “telehealth” and “telemedicine” was used in keyword searches. Thematic analysis and synthesis of each paper was conducted, aligned to the framework developed by Beauchamp and Childress.

Results

From the 49 papers reviewed, authors identified or discussed the following ethical principles in relation to telehealth practice: autonomy (69% of authors, 34/49), professional–patient relationship (53% of authors, 26/49), nonmaleficence (41% of authors, 20/49), beneficence (39%, of authors, 19/49), and justice (39% of authors, 19/49).

Conclusions

Although a small number of studies identified ethical issues associated with telehealth practice and discussed their potential impact on service quality and effectiveness, there is limited research on how ethical principles are incorporated into clinical practice. Several studies proposed frameworks, codes of conduct, or guidelines, but there was little discussion or evidence of how these recommendations are being used to improve ethical telehealth practice.

Exploring the acceptance of telehealth within palliative care: A self-determination theory perspective

The aim of this paper was to explore potential divergence and convergence in relation to health care professionals’ and patients’ acceptability of the use of telehealth within palliative care provision through the lens of Self-Determination Theory. The research utilized a deductive qualitative approach utilizing semi-structured interviews to explore divergence and convergence between health care professionals’ preconceptions of the use of telehealth in palliative care and the lived experiences of patients accessing support in this manner. Semi-structured interviews were conducted with both professionals and patients to explore whether the barriers and benefits of telehealth perceived by professionals corresponded to the patient’s lived experience of utilizing the technology in their palliative care. Interviews were analyzed using a deductive thematic analysis. Professionals and patients identified that the use of telehealth could satisfy the need for autonomy, however this manifested in different ways. Greater divergence was apparent between patient and professional perceptions about how telehealth could satisfy the need for relatedness and competence needs. The findings of this paper highlight how professionals preconceived concerns about the use of telehealth in relation to providing supportive palliative care may not be realized when exploring the experiences of patients accessing services through this medium. This paper highlights the important role of psychological need satisfaction when considering acceptability of telehealth, and motivation to engage in the implementation of technologically driven health services.

Human Touch via Touchscreen: Rural Nurses' Experiential Perspectives on Telehealth Use in Pediatric Hospice Care

CONTEXT

Telemedicine has the potential to extend care reach and access to home-based hospice services for children. Few studies have explored nurse perspectives regarding this communication modality for rural pediatric cohorts.

OBJECTIVES

The objective of this qualitative study was to learn from the experiences of rural hospice nurses caring for children at the end of life using telehealth modalities to inform palliative communication.

METHODS

Voice-recorded qualitative interviews with rural hospice nurse telehealth users inquiring on nurse experiences with telehealth. Semantic content analysis was used.

RESULTS

About 15 hospice nurses representing nine rural hospice agencies were interviewed. Nurses participated in an average of eight telehealth visits in the three months prior. Nurses were female with a mean age of 38 years and an average of seven years of hospice nursing experience. Five themes about telehealth emerged: accessible support, participant inclusion, timely communication, informed and trusted planning, and familiarity fostered. Each theme had both benefits and cautions associated as well as telehealth suggestions. Nurses recommended individualizing communication, pacing content, fostering human connection, and developing relationships even with technology use.

CONCLUSION

The experiences of nurses who use telehealth in their care for children receiving end-of-life care in rural regions may enable palliative care teams to understand both the benefits and challenges of telehealth use. Nurse insights on telehealth may help palliative care teams better honor the communication needs of patients and families while striving to improve care access.

Web-based videoconferencing for rural palliative care consultation with elderly patients at home

PURPOSE

Providing specialized palliative care support to elderly patients in rural areas can be challenging. The purpose of this study was to gain a preliminary understanding of the experience of using mobile web-based videoconferencing (WBVC) for conducting in-home palliative care consults with elderly rural patients with life-limiting illness.

METHODS

This was a descriptive, exploratory, proof-of-concept study with a convenience sample of 10 WBVC visits. A palliative care clinical nurse specialist (PC-CNS), in the home with the patient/family and home care nurse (HC-N), used a laptop computer with webcam and speakerphone to connect to a distant palliative care physician consultant (PC-MD) over a secure Internet connection. Data was collected using questionnaires, interviews, and focus groups.

RESULTS

Analysis of qualitative data revealed four themes: communication, logistics, technical issues, and trust. Participants reported they were comfortable discussing concerns by WBVC and felt it was an acceptable and convenient way to address needs. Audiovisual quality was not ideal but was adequate for communication. Use of WBVC improved access and saved time and travel. Fears were expressed about lack of security of information transmitted over the Internet.

CONCLUSIONS

Using WBVC for in-home palliative care consults could be an acceptable, effective, feasible, and efficient way to provide timely support to elderly rural patients and their families. Having a health care provider in the home during the WBVC is beneficial. WBVC visits have advantages over telephone calls, but limitations compared to in-person visits, suggesting they be an alternative but not replacement for in-person consultations.

Balancing Health Information Exchange and Privacy Governance from a Patient-Centred Connected Health and Telehealth Perspective

Objectives:  Connected healthcare is an essential part of patient-centred care delivery. Technology such as telehealth is a critical part of connected healthcare. However, exchanging health information brings the risk of privacy issues. To better manage privacy risks we first need to understand the different patterns of patient-centred care in order to tailor solutions to address privacy risks.

Methods:  Drawing upon published literature, we develop a business model to enable patient-centred care via telehealth. The model identifies three patient-centred connected health patterns. We then use the patterns to analyse potential privacy risks and possible solutions from different types of telehealth delivery.

Results:  Connected healthcare raises the risk of unwarranted access to health data and related invasion of privacy. However, the risk and extent of privacy issues differ according to the pattern of patient-centred care delivery and the type of particular challenge as they enable the highest degree of connectivity and thus the greatest potential for privacy breaches.

Conclusion:  Privacy issues are a major concern in telehealth systems and patients, providers, and administrators need to be aware of these privacy issues and have guidance on how to manage them. This paper integrates patient-centred connected health care, telehealth, and privacy risks to provide an understanding of how risks vary across different patterns of patient-centred connected health and different types of telehealth delivery.

Keep in Touch (KIT): feasibility of using internet-based communication and information technology in palliative care

BACKGROUND

Confinement to an in-patient hospital ward impairs patients' sense of social support and connectedness. Providing the means, through communication technology, for patients to maintain contact with friends and family can potentially improve well-being at the end of life by minimizing social isolation and facilitating social connection. This study aimed to explore the feasibility of introducing internet-based communication and information technologies for in-patients and their families and to describe their experience in using this technology.

METHODS

A cross-sectional survey design was used to describe patient and family member experiences in using internet-based communication technology and health care provider views of using such technology in palliative care. Participants included 13 palliative in-patients, 38 family members, and 14 health care providers. An iPad or a laptop computer with password-protected internet access was loaned to each patient and family member for about two weeks or they used their own electronic devices for the duration of the patient's stay. Quantitative and qualitative data were collected from patients, families, and health care providers to discern how patients and families used the technology, its ease of use and its impact. Descriptive statistics and paired sample t-tests were used to analyze quantitative data; qualitative data were analyzed using constant comparative techniques.

RESULTS

Palliative patients and family members used the technology to keep in touch with family and friends, entertain themselves, look up information, or accomplish tasks. Most participants found the technology easy to use and reported that it helped them feel better overall, connected to others and calm. The availability of competent, respectful, and caring technical support personnel was highly valued by patients and families. Health care providers identified that computer technology helped patients and families keep others informed about the patient's condition, enabled sharing of important decisions and facilitated access to the outside world.

CONCLUSIONS

This study confirmed the feasibility of offering internet-based communication and information technologies on palliative care in-patient units. Patients and families need to be provided appropriate technical support to ensure that the technology is used optimally to help them accomplish their goals.

How outpatient palliative care teleconsultation facilitates empathic patient-professional relationships: a qualitative study

OBJECTIVE

The problems and needs of advanced cancer patients and proxies normally increase as the disease progresses. Home-based advanced cancer patients and their proxies benefit from collaborations between primary care physicians and hospital-based palliative care specialists when confronted with complex problems in the last phase of life. Telemedicine might facilitate direct, patient-centered communication between patients and proxies, primary care physicians, and specialist palliative care teams (SPCTs). This study focuses on the impact of teleconsultation technologies on the relationships between home-based palliative care patients and hospital-based palliative care specialists.

METHODS

This work consists of a qualitative study among patients, family members, and caregivers that utilizes long-term direct observations, semi-structured interviews, and open interviews following the observations.

RESULTS

The analysis of the empirical data resulted in three key concepts that describe the impact of teleconsultation on the patient-professional relationship in palliative homecare: transcending the institutional walls of home and hospital; transparency of teleconsultation technology; and technologized, intimate patient-professional relationships. Teleconsultation offers (1) condensed encounters between home-based palliative care patients and distant professionals, (2) a unique insight into the patients' daily lives for palliative care specialists, and (3) long-term interaction that results in trustful relationships and experiences of intimacy and relief.

CONCLUSIONS

Teleconsultation fits the practice of home-based palliative care. Teleconsultation can, if well applied, facilitate computer-mediated but empathic patient-palliative care specialist relationships, which enable professional care attuned to the patient's context as well as patient involvement. This article proposes a teleconsultation implementation guide for optimal use of teleconsultation in daily palliative care practice.

The power(s) of observation: Theoretical perspectives on surveillance technologies and older people

There is a long history of surveillance of older adults in institutional settings and it is becoming an increasingly common feature of modern society. New surveillance technologies that include activity monitoring, and ubiquitous computing, which are described as ambient assisted living (AAL) are being developed to provide unobtrusive monitoring and support of activities of daily living and to extend the quality and length of time older people can live in their homes. However, concerns have been raised with how these kinds of technologies may affect user's privacy and autonomy. The objectives of this paper are 1) to describe the development of home-based surveillance technologies; 2) to examine how surveillance is being restructured with the use of this technology; and 3) to explore the potential outcomes associated with the adoption of AAL as a means of surveillance by drawing upon the theoretical work of Foucault and Goffman. The discussion suggests that future research needs to consider two key areas beyond the current discourse on technology and ageing, specifically: 1) how the new technology will encroach upon the private lived space of the individual, and 2) how it will affect formal and informal caring relationships. This is critical to ensure that the introduction of AAL does not contribute to the disempowerment of residents who receive this technology.

Digital support for medication administration--a means for reaching the goal of providing good care?

PURPOSE

The purpose of this paper is to describe staffs' perceptions of digital support for medication administration (DSM) and out of the perceptions interpret underlying values.

DESIGN/METHODOLOGY/APPROACH

In total, 22 persons working in elder care participated in the study. The study had a qualitative approach and focus group interviews were used to collect data. To analyze the manifest content a phenomenographic method was used. An interpretation of perceptions was then undertaken aimed at identifying underlying values.

FINDINGS

Three descriptive categories, "utility," "impact on working environment" and "economic impact" were the result of the manifest analysis. The values of having a "good working environment," "benefits" and "good economy" were interpreted as guidance for staffs' acceptance or rejection of the DSM.

SOCIAL IMPLICATIONS

The care-giving process and its challenges from the perspective of the staffs need consideration. Staffs in this study sometimes expressed strong emotions as a sign of frustration for losing prerequisites to perform their work well. In big complex organizations where economy and effectiveness are often discussed, knowledge of power relations in innovation and implementation processes would be beneficial. Although moral distress is a well-known phenomenon, future research may be needed to find solutions that diminish this negative trend in more economic focussed organizations.

ORIGINALITY/VALUE

This study had a twofold approach with the intention of going beyond descriptions. To gain a deeper understanding a normative interpretation was completed. Ethical conflicts are frequently characterized as conflicts between at least two values. In this study staffs expressed fear of losing prerequisites needed to perform their work well. Prerequisites that were identified as values and these values were threatened by the DSM.

Home telehealth and paediatric palliative care: clinician perceptions of what is stopping us?

Background

Advances in technology have made the use of telehealth in the home setting a feasible option for palliative care clinicians to provide clinical care and support. However, despite being widely available and accessible, telehealth has still not been widely adopted either in Australia or internationally. The study aim was to investigate the barriers, enablers and perceived usefulness for an established home telehealth program in paediatric palliative care from the perspective of clinicians.

Methods

Semi-structured interviews (n = 10) were undertaken with palliative care clinicians in a tertiary paediatric hospital to identify attitudes to, satisfaction with, and perceived benefits and limitations of, home telehealth in palliative care. Iterative analysis was used to thematically analyse data and identify themes and core concepts from interviews.

Results

Four themes are reported: managing relationships; expectations of clinicians; co-ordination, and the telehealth compromise. Core concepts that emerged from the data were the perceived ability to control clinical encounters in a virtual environment and the need to trust technology. These concepts help explain the telehealth compromise and low utilisation of the home telehealth program.

Conclusions

Effective communication between caregivers and clinicians is recognised as a core value of palliative care. Home telehealth has the potential to provide a solution to inequity of access to care, facilitate peer support and maintain continuity of care with families. However, significant limitations and challenges may impede its use. The virtual space creates additional challenges for communication, which clinicians and families may not intuitively understand. For home telehealth to be integrated into routine care, greater understanding of the nature of communication in the virtual space is required.

Policy expectations and reality of telemedicine - a critical analysis of health care outcomes, costs and acceptance for congestive heart failure

A critical review of evidence was carried out to discover whether the actual performance of telemedicine fulfils the expectations of German policy-makers. The analysis was conducted using the example of telemedicine for congestive heart failure (CHF). It was based on both German and international evidence. The PubMed, MEDLINE, Google Scholar and Cochrane Library databases were searched, as well as public sources from the German Federal Ministry of Health. Forty-five studies reporting patient outcomes, costs or acceptance of telemedicine for CHF were included in the review, of which 28 were interventional. The policy expectations of telemedicine generally are: high technology acceptance and improved patient outcomes at lower costs. However, in the field of CHF, policy-makers underestimate the complexity of telemedicine and the technology has not yet lived up to its expectations. Although some studies show improvements in all-cause mortality and CHF-related hospitalisations, there is excessive study heterogeneity and vagueness in the areas of costs and acceptance. Methodological insufficiencies as well as the scarcity of evidence in the German context do not allow definite conclusions to be drawn. Policy-makers and other stakeholders should increase their efforts to consolidate isolated telemedicine projects, establish guidelines for clinical treatment procedures and economic evaluations, and define industry/technical device standards to enhance the comparability of interventions. Imposing the use of telemedicine on patients and physicians is not likely to be fruitful. A successful adaptation requires an analysis of needs and continuous education on both sides.

Connecting with patients and instilling realism in an era of emerging communication possibilities: a review on palliative care communication heading to telecare practice

OBJECTIVE

Appropriate palliative care communication is pivotal to optimizing the quality of life in dying patients and their families. This review aims at describing communication patterns in palliative care and discussing potential relations between communication patterns and upcoming telecare in the practice of palliative care.

METHODS

This review builds on a systematic five-step qualitative analysis of the selected articles: 1. Development of a 'descriptive table of studies reviewed' based on the concept of genre, 2. Open coding of table content and first broad clustering of codes, 3. Intracluster categorization of inductive codes into substantive categories, 4. Constant inter- and intracluster comparison results in identification of genres, and 5. Labeling of genres.

RESULTS

This review includes 71 articles. In the analysis, two communication genres in palliative care proved to be dominant: the conversation to connect, about creating and maintaining a professional-patient/family relationship, and the conversation to instill realism, about telling a clinical truth without diminishing hope.

CONCLUSION

The abovementioned two genres clarify a logical intertwinement between communicative purposes, the socio-ethical background underlying palliative care practice and elements of form.

PRACTICE IMPLICATIONS

Our study supports understanding of current communication in palliative care and anticipates future communicative actions in an era of new communication technologies.

Ethical challenges with welfare technology: a review of the literature

Demographical changes in high income counties will increase the need of health care services but reduce the number of people to provide them. Welfare technology is launched as an important measure to meet this challenge. As with all types of technologies we must explore its ethical challenges. A literature review reveals that welfare technology is a generic term for a heterogeneous group of technologies and there are few studies documenting their efficacy, effectiveness and efficiency. Many kinds of welfare technology break with the traditional organization of health care. It introduces technology in new areas, such as in private homes, and it provides new functions, e.g. offering social stimuli and entertainment. At the same time welfare technology is developed for groups that traditionally have not been extensive technology users. This raises a series of ethical questions with regard to the development and use of welfare technologies, which are presented in this review. The main challenges identified are: (1) Alienation when advanced technology is used at home, (2) conflicting goals, as welfare technologies have many stakeholders with several ends, (3) respecting confidentiality and privacy when third-party actors are involved, (4) guaranteeing equal access and just distribution, and (5) handling conflicts between instrumental rationality and care in terms of respecting dignity and vulnerability. Addressing these issues is important for developing and implementing welfare technologies in a morally acceptable manner.

The case for home based telehealth in pediatric palliative care: a systematic review

Background

Over the last decade technology has rapidly changed the ability to provide home telehealth services. At the same time, pediatric palliative care has developed as a small, but distinct speciality. Understanding the experiences of providing home telehealth services in pediatric palliative care is therefore important.

Methods

A literature review was undertaken to identify and critically appraise published work relevant to the area. Studies were identified by searching the electronic databases Medline, CINAHL and Google Scholar. The reference list of each paper was also inspected to identify any further studies.

Results

There were 33 studies that met the inclusion criteria of which only six were pediatric focussed. Outcome measures included effects on quality of life and anxiety, substitution of home visits, economic factors, barriers, feasibility, acceptability, satisfaction and readiness for telehealth. While studies generally identified benefits of using home telehealth in palliative care, the utilisation of home telehealth programs was limited by numerous challenges.

Conclusion

Research in this area is challenging; ethical issues and logistical factors such as recruitment and attrition because of patient death make determining effectiveness of telehealth interventions difficult. Future research in home telehealth for the pediatric palliative care population should focus on the factors that influence acceptance of telehealth applications, including goals of care, access to alternative modes of care, perceived need for care, and comfort with using technology.

A qualitative study of ethical, medico-legal and clinical governance matters in Australian telehealth services

We examined how Australian telehealth service providers perceived and addressed ethical, medico-legal and clinical governance matters arising from service delivery. Thirty-seven telehealth clinicians and managers were interviewed and a qualitative content analysis was conducted. The services covered six Australian jurisdictions and a range of clinical disciplines. There were 11 medical specialities, surgery, mental health, paediatrics, nursing and allied health. Thirty services (83%) used video consulting and 25 (68%) delivered services to rural areas. Telehealth was reported to be beneficial by reducing adverse events, improving health outcomes, offering increased patient choice of service delivery, and improving access to services for rural areas and home care. There were observations of gains or no change in patient-provider rapport compared to face-to-face communication, with some patients reportedly preferring video. Those interviewed reported some problems with privacy and security, and variable informed consent practices. No examples of malpractice were raised, although there was a common misperception that distant providers were not responsible for clinical care. With respect to clinical governance, telehealth was seen as enabling improved quality, integration and implementation of evidence-based care, and to be a major support for the rural health workforce. Although there were potential ethical, medico-legal and governance problems in Australian telehealth services, these had been easily managed in practice.

Technologies to support end-of-life care

OBJECTIVES

To describe the current level of utilization of informatics systems in hospice and palliative care and to discuss two projects that highlight the role of informatics applications for hospice informal caregivers.

DATA SOURCES

Published articles, Web resources, clinical practice, and ongoing research initiatives.

CONCLUSION

There are currently few informatics interventions designed specifically for palliative and hospice care. Challenges such as interoperability, user acceptance, privacy, the digital divide, and allocation of resources all affect the diffusion of informatics tools in hospice.

IMPLICATIONS FOR NURSING PRACTICE

Caregiver support through use of information technology is feasible and may enhance hospice care.

UK telehealth initiatives in palliative care: a review

This review paper explores the use of telehealth in relation to palliative care in the UK. Information technology (IT) developments are being harnessed throughout society, and there is growing interest in the ways in which they can be used to meet and support patients' health needs in the community. The aim of the literature review was to scope the information available from published and unpublished research, with particular reference to older people. The evidence suggests that, despite the challenges, there are numerous examples of good practice in relation to telehealth, palliative and end-of-life care, and older people. Developments in technology that have increased the capacity to improve care, through reaching greater numbers of people of all age groups, mean that telehealth has much to offer people living with and dying from advanced illness. However, some of the evaluative evidence is limited and further rigour is needed when evaluating future telehealth innovations.

Telehealth in palliative care in the UK: a review of the evidence

We reviewed telehealth applications which were being used in palliative care settings in the UK. Electronic database searches (Medline, CINAHL, PsychInfo and Embase), searches of the grey literature and cited author searches were conducted. In total, 111 papers were identified and 21 documents were included in the review. Telehealth was being used by a range of health professionals in oncology care settings that included specialist palliative care, hospices, primary care settings, nursing homes and hospitals as well as patients and carers. The most common applications were: out-of-hours telephone support, advice services for palliative care patients, carers and health professionals, videoconferencing for interactive case discussions, consultations and assessments, and training and education of palliative care and other health-care staff. The review suggests that current technology is usable and acceptable to patients and health professionals in palliative care settings. However, there are several challenges in integrating telehealth into routine practice.

Ethical considerations regarding the use of technology for older adults. The case of telehealth

Life expectancy increases and ongoing growth of the population older than 65 have led to new models of aging research aimed at promoting independence and empowerment of older adults. Advances in information technology have introduced numerous ways to enhance or expand health care and support service research and development. The purpose of this article is to discuss ethical considerations associated with the use of technology with older adults in research and practice and to present a framework for such ethical parameters. Specifically, we focus on the case of telehealth and discuss examples from the Native People for Cancer Control Telehealth Network to exemplify the framework. The proposed framework includes the concepts of privacy, informed consent, equity of access, patient-provider communication, and usability. These issues constitute a roadmap for researchers, practitioners, system designers, policy makers, and administrators who aim to conduct ethical research that results in improved care and support services to older adults and increase health care access for rural and underserved populations.

Swedish district nurses' attitudes to implement information and communication technology in home nursing

The use of information and communication technology has increased in the society, and can be useful in nursing care. The aim of this study was to describe district nurses' attitudes regarding the implementation of information and communication technology in home nursing. The first and third authors performed five focus group discussions with 19 district nurses' from five primary healthcare centres in northern Sweden. During the focus group discussions, the following topics were discussed: the current and future use of information and communication technology in home nursing; expectations, advantages, disadvantages and hindrances in the use of information and communication technology in home nursing; and the use of information and communication technology from an ethical perspective. The transcribed focus group discussions were analysed using qualitative content analysis. The results showed that district nurses' attitudes were positive regarding the use of information and communication technology in their work. They also asked for possibilities to influence the design and its introduction. However, the use of information and communication technology in home nursing can be described as a complement to communication that could not replace human physical encounters. Improvements and risks, as well as the importance of physical presence in home nursing were considered vital. The results revealed that the use of information and communication technology requires changes in the district nurses' work situation.

A review of smart homes- present state and future challenges

In the era of information technology, the elderly and disabled can be monitored with numerous intelligent devices. Sensors can be implanted into their home for continuous mobility assistance and non-obtrusive disease prevention. Modern sensor-embedded houses, or smart houses, cannot only assist people with reduced physical functions but help resolve the social isolation they face. They are capable of providing assistance without limiting or disturbing the resident's daily routine, giving him or her greater comfort, pleasure, and well-being. This article presents an international selection of leading smart home projects, as well as the associated technologies of wearable/implantable monitoring systems and assistive robotics. The latter are often designed as components of the larger smart home environment. The paper will conclude by discussing future challenges of the domain.

Patient-centered applications: use of information technology to promote disease management and wellness. A white paper by the AMIA knowledge in motion working group

Advances in information technology (IT) enable a fundamental redesign of health care processes based on the use and integration of electronic communication at all levels. New communication technologies can support a transition from institution centric to patient-centric applications. This white paper defines key principles and challenges for designers, policy makers, and evaluators of patient-centered technologies for disease management and prevention. It reviews current and emerging trends; highlights challenges related to design, evaluation, reimbursement and usability; and reaches conclusions for next steps that will advance the domain.