Recruitment Challenges for End-of-Life Research

Challenges and Opportunities in Designing and Deploying Remote Health Monitoring Technology for Older Adults With Cancer

Remote health monitoring (RHM) technologies (eg, wearables, smart phones, embedded sensors, and telehealth platforms) offer significant opportunities to improve health and wellness for older adults facing serious illness. This article highlights key challenges and opportunities for designing and deploying RHM systems in the context of caring for older adults with cancer, with an emphasis on the key role nurses can play in this work. Focal topics include user-centered design, interdisciplinary collaboration, addressing health inequities and disparities, privacy and data security, participant recruitment and burden, personalized and tailored care, rapid technological change, family caregiver perspectives, and naturalistic data collection. It is critical for nurses to be aware of both challenges and opportunities within each of these areas in order to develop RHM systems that are optimally beneficial for patients, family caregivers, clinicians, and organizations. By leveraging their unique knowledge of the illness experience from the patient, family, and health care provider perspective, nurses can make essential clinical and scientific contributions to advance the field of RHM.

Methodological Reflections on the Recruitment of Adult Child-Parent Dyads for End-of-Life Research in Germany: Experiences From the Dy@EoL Study

CONTEXT

Although high-quality research with patients and family members is needed to improve palliative care, difficulties in recruitment are often reported.

OBJECTIVES

The present article analyzes the authors' experiences in recruiting participants of two types of dyads for the study "Dy@EoL-Interaction at the end of life in dyads of parents and adult children". Recruitment challenges and factors found to improve recruitment are examined.

METHODS

Between February 2018 and November 2019, the research team cooperated with diverse inpatient and ambulatory palliative and hospice care providers to recruit both dyads. Cooperation strategies and adaptations were protocolled. Data on (non-)participation were recorded and analyzed using descriptive statistics.

RESULTS

The recruitment rate was 34.6% (dyad 1, terminally ill adult children with parents: 36.4%; dyad 2, terminally ill parents with adult children: 33.9%). In total, 82.2% of participants were recruited from inpatient settings. The research team has applied various strategies, such as public outreach activities and the extension of recruitment partners. The study protocol was adapted at an early stage to include single participants. Of all patients, 47.7% participated without their dyad partner. The main reason to exclude their family member was the patients' wish to protect them from extraburden.

CONCLUSION

The recruitment was more successful in inpatient than in ambulatory settings. The extension of recruitment partners was beneficial to recruit participants from ambulatory contexts. The inclusion of single participants was conducive as a great number of patients participated without their dyad partner. Sharing the obtained experiences can be helpful for future research planning.

The art and science of recruitment to a cancer rapid autopsy programme: A qualitative study exploring patient and clinician experiences

BACKGROUND

CASCADE is a successful, Australia-first cancer rapid autopsy programme. Patients are recruited to the programme by their clinician once they understand that further treatment has only palliative intent. Despite its value, rapid autopsy is a rare research method owing partly to recruitment challenges.

AIM

This research aimed to explore (1) how, in practice, clinicians select and recruit patients to the programme and (2) patient experiences of this process.

DESIGN

This was a qualitative study grounded in phenomenology. CASCADE team members (clinicians and researchers) and patients participated in semi-structured interviews. Data were analysed using an inductive, team-based approach to thematic analysis.

PARTICIPANTS

Interviews were conducted with 31 participants (11 patients and 20 CASCADE team members).

RESULTS

Patient selection and recruitment to a rapid autopsy programme is both an art and science. In practice, patient selection is a subjective process that involves assessing a patient's psychosocial suitability for the programme. Trust and rapport are necessary for informing this assessment and to create an environment conducive to discussing rapid autopsy. Clinicians have also crafted their own ways of delivering information about CASCADE, with both clinicians and patients acknowledging that, if not handled sensitively, recruitment could cause distress. Overall, patients were satisfied with the way in which they were recruited.

CONCLUSION

Findings provide insight into how clinicians successfully select and recruit patients to a rapid autopsy programme and suggests that discussing such topics are acceptable to end-of-life patients. This research also raises thought-provoking questions about the 'gatekeeping' role of clinicians in recruitment.

Feasibility, acceptability, and tolerability of RGN107 in the palliative wound care management of chronic wound symptoms

OBJECTIVE

To assess the feasibility, acceptability and tolerability of RGN107 use, a natural powder blend of Arnica Montana, Calendula Officinalis, Mentha Arvensis and Santalum Album, among hospice patients and their wound caregivers in the palliative wound care management of chronic wound symptoms at end-of-life.

METHOD

Data were collected between May 2013 and November 2015. A pilot trial conducted among 50 hospice patients with symptomatic (pain, odour, or exudate) chronic wounds. Caregivers received initial RGN107 protocol training, actively applied the powder to patient wounds for 4-weeks, and completed an 8-week retrospective survey. Feasibility was assessed by measuring process outcomes, including the number and proportion of participants referred, screened eligible, enrolled, withdrawn and successfully completed. Acceptability measures included: a protocol training evaluation, caregiver pre and post self-efficacy ratings, retrospective usability, symptom control management and comparative technique caregiver ratings, and recorded open-ended comments. Tolerability was assessed through a 12-week cumulative review of the study adverse event profile.

RESULTS

Feasibility, tolerability and acceptability of use of the RGN107 powder for chronic wounds were established. Recruitment goals were achieved and 92 % of the patients successfully completed the study. 95 % of wound caregivers would recommend the powder for use in this population.

CONCLUSION

This study supports the feasibility, acceptability and tolerability of a wound care powder that espouses a multi-symptom palliative comfort care approach for hospice patients with chronic wounds at end-of-life. Further research is needed to establish the efficacy of the powder.

Research at the End of Life

Conducting research at the end of life is currently a priority for the National Institute of Nursing Research, the Institute of Medicine, and the National Institute of Health. However, attempting to do research with those who are dying is fraught with numerous challenges. In this column, the author discusses some of the issues and presents viable solutions, so that we as the research community can inform clinicians about care at the end of life and improve quality.

Illness perceptions, adjustment to illness, and depression in a palliative care population

CONTEXT

Representations of illness have been studied in several populations, but research is limited in palliative care.

OBJECTIVES

To describe illness representations in a population with advanced disease receiving palliative care and to examine the relationship between illness perceptions, adaptive coping, and depression.

METHODS

A cross-sectional survey of 301 consecutive eligible patients recruited from a palliative care service in south London, U.K. Measures used included the Brief Illness Perception Questionnaire (Brief IPQ), the Mental Adjustment to Cancer (MAC) Scale, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-9.

RESULTS

Scores were not normally distributed for most questions on the Brief IPQ. The correlations found between items on the Brief IPQ were understandable in the context of advanced disease. MAC helplessness-hopelessness and fighting spirit were highly correlated with items on the Brief IPQ in opposite directions. The Brief IPQ domains of consequences, identity, concern, personal control, and emotion were associated with depression, a relationship that was not explained by adaptive coping. Seven causal attribution themes were identified: don't know, personal responsibility, exposure, pathological process, intrinsic personal factors, chance, fate or luck, and other. Both lung cancer diagnosis and gender were found to be independently associated with personal responsibility attribution. None of the attribution themes were associated with the presence of depression.

CONCLUSION

Assessment of illness perceptions in palliative care is likely to yield important information about risk of depression and will help clinicians to personalize management of advanced disease.

Clinician views of referring people with negative symptoms to outcome research: a questionnaire survey

This paper reports on a survey of mental health clinician views of including people with psychosis and negative symptoms in outcome research. A questionnaire was forwarded to clinicians (the majority of whom were mental health nurses) completing post-registration undergraduate and postgraduate degree courses in psychosocial interventions for psychosis. Fifty questionnaires were returned (a response rate of 84.7%). A total of 47% of respondents indicated that they might refrain from offering this group as potential participants to clinical trials. Thematic analysis suggests views that negative symptoms are not amenable to treatment inform such decisions. The results highlight the potential difficulties faced by researchers investigating new treatments for people with negative symptoms, and suggest further exploration of clinician views of referring this group to research and psychosocial treatments is warranted.

The acceptability of e-technology to monitor and assess patient symptoms following palliative radiotherapy for lung cancer

E-technology is increasingly used in oncology to obtain self-reported symptom assessment information from patients, although its potential to provide a clinical monitoring tool in palliative care is relatively unexplored in the UK. This study aimed to evaluate the support provided to lung cancer patients post palliative radiotherapy using a computerized assessment tool and to determine the clinical acceptability of the tool in a palliative care setting. However, of the 17 clinicians identified as managing patients who met the initial eligibility criteria for the study, only one clinician gave approval for their patient to be contacted regarding participation, therefore the benefits of this novel technology could not be assessed. Thirteen key clinicians from the centres involved in the study were subsequently interviewed. They acknowledged potential benefits of incorporating computerized patient assessment from both a patient and practice perspective, but emphasized the importance of clinical intuition over standardized assessment. Although clinicians were positive about palliative care patients participating in research, they felt that this population of patients were normally too old, with too rapidly deteriorating a condition to participate in a study using e-technology. In order to encourage acceptance of e-technology within palliative care, emphasis is needed on actively promoting the contribution of technologies with the potential to improve patient outcomes and the patient experience.

Research Recruitment in Home Care in an Era of Scams and Advocacy

Recruitment is the cornerstone of research involving human beings. Most of what has been written involved institutional recruitment, yet the past two decades have seen an exponential rise in the delivery of home care. This shift has been accompanied by an increase in the volume of research conducted in homecare, and the majority of home care recipients are elderly. The elderly experience a disproportionate occurrence of consumer fraud and are increasingly reluctant to give strangers access to their homes. Advocacy groups have made formidable contributions to raising the awareness among older persons of risks to their person and finances. The aim of this article is to raise awareness of the importance of recruitment in the home care community and to recommend to researchers that they partner with community agencies and advocacy groups to inform citizens of the value of their participation in research in home care, and the benefits.

Exploring generalizability in a study of costs for community-based palliative care

CONTEXT

Palliative care researchers face challenges recruiting and retaining study subjects.

OBJECTIVES

This article investigates selection, study site, and participation biases to assess generalizability of a cost analysis of palliative care program (PCP) clients receiving care at home.

METHODS

Study subjects' sociodemographic, geographic, survival, disease, and treatment characteristics were compared for the same year and region with those of three populations. Comparison I was with nonstudy subjects enrolled in the PCP to assess selection bias. Comparison II was with adults who died of cancer to assess study site bias. Comparison III was with study-eligible persons who declined to participate in order to assess participation bias.

RESULTS

Comparison I: When compared with the other 1010 PCP clients, the 50 study subjects were on average 3.6 years younger (P=0.03), enrolled 70 days longer in the PCP (P<0.001), lived 6.7 km closer to the PCP (P<0.0001), and were more likely to have cancer (96.0% vs. 86.4%, P=0.05). Comparison II: Compared with all cancer decedents, the 45 study subjects who died of cancer were on average 7.0 years younger (P<0.001), lived 2.7 km closer to the PCP (P<0.001), and were more likely to have had radiotherapy (62.2% vs. 33.8%, P<0.0001) and medical oncology (28.9% vs. 14.8%, P=0.01) consultations. Comparison III: The 50 study subjects lived on average 42 days longer after their diagnosis (P=0.03) and 2.6 km closer to the PCP (P=0.01) than the 110 eligible persons who declined to participate.

CONCLUSION

If the study findings are applied to populations that differ from the study subjects, inaccurate conclusions are possible.

A systematic review examining the literature on attitudes of patients with advanced cancer toward research

The attitudes of heterogeneous groups of cancer patients towards research have been studied extensively. Less is known about these attitudes in the advanced cancer population. Such patients may have differing attitudes for a variety of reasons, including burden of disease and social factors. This systematic review examines the literature on attitudes of patients with advanced cancer toward research and aims to define common themes. The following databases were searched electronically: CINAHL (1982-2007), the Cochrane Database of Systematic Reviews (2007), Embase (1996-2007), and Medline (1996-2007). Additionally, the following journals were hand searched: Palliative Medicine, Journal of Pain and Symptom Management, and the European Journal of Palliative Care. The search terminologies used were: "Cancer" AND "Attitudes" AND "Research" AND "Palliative Care." All subheadings were included. Results were limited to English-language journals and studies involving humans. Of the 637 articles retrieved, 11 were included after an appraisal process. Both positive and negative attitudes toward research in advanced cancer were identified. Common themes of altruism, hope, and self-benefit were identified in 10 studies as a motivation for trial participation. Negative attitudes toward symptom control and risk of increased hospital admissions were identified in four studies. Most of the studies involved patients' views about participating in hypothetical trials, limiting the generalizability of results. An important step for future work would be to examine the experiences and opinions of patients with advanced cancer who have actually participated in a clinical trial.