Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis

Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life

BACKGROUND

Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals.

METHODS

Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life.

RESULTS

Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04).

CONCLUSIONS

Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.

An Evolutionary Concept Analysis of Palliative Care in Oncology Care

This evolutionary concept analysis reports on the concept of palliative care in oncology. Despite its relevance to oncology, the concept of palliative care remains misunderstood, resulting in erroneous interpretations by nurses and health care providers alike. Consequently, integration of palliative care remains heterogeneous and highly contextual. Findings highlight the complexity and ambiguity of the concept of palliative care in the context of oncology care. The nuances and complexity of when to integrate palliative care for patients living with cancer, as well as its evolution from its origins in the hospice movement, have led to its ambiguity in clinical practice.

Spanish Nurses' Knowledge about Palliative Care. A National Online Survey

(1) Background: Nurses can find people with advanced diseases or in their last days of life during their professional careers and in many different care settings. For this reason, they need to have at least a basic level of palliative care education since they are the professional cohort treating these patients in a very close way. This research aims to determine the level of knowledge in palliative care of Spanish nurses and establish any possible difference based on their experience and training in palliative care. (2) Methods: A cross-sectional design using survey methods (distributed an online questionnaire) aimed at Spanish registered nurses. A validated questionnaire (PCQN-SV) was used to determine the level of knowledge in palliative care; information on some variables to characterize the population was also collected (experience and education in palliative care, years of professional experience, academic level, and others). Uni and bivariate descriptive analyses were performed. A binary logistic regression model was also developed to identify those variables that influenced obtaining results higher than the population’s average. (3) Results: Spanish nurses have a medium–low level of knowledge in palliative care, higher in those who have previous experience or education in this area. Statistically significant differences were also found according to the area in which their caring activity was developed. (4) Conclusions: It is necessary to implement strategies for the basic training of nursing professionals in palliative care to offer quality care to people in advanced stages of illnesses or at the end of their lives.

(Dis)Connecting Through COVID-19: Experiences of Older Persons in the Context of a Volunteer-Client Relationship

The coronavirus (COVID-19) pandemic and mandated physical distancing requirements significantly impacted volunteer programs for older persons with many long-standing programs either ceasing altogether or pivoting to connecting through virtual technologies. In this study, we collected qualitative interview data from 23 clients and 33 volunteers to investigate their experiences during the COVID-19 pandemic and the effects on the volunteer-client relationship. Three themes were identified: pandemic emotions, negotiating social interactions, and growing through the COVID-19 pandemic. These findings provide important insights into the experiences of hospice organizations and their volunteers and clients during the COVID 19 pandemic, further highlighting the importance of acknowledging both older persons' vulnerability and their resilience, of building in compassionate community approaches to care, and of finding innovative ways to foster volunteer-client relationships during times when physical visiting is not possible.

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

'Bare-bones' to 'silver linings': lessons on integrating a palliative approach to care in long-term care in Western Canada

Background

‘Whole-person’ palliative approaches to care (PAC) are important for enhancing the quality of life of residents with life-limiting conditions in long-term care (LTC). This research is part of a larger, four province study, the ‘SALTY (Seniors Adding Life to Years)’ project to address quality of care in later life.

A Quality Improvement (QI) project to integrate a PAC (PAC-QI) in LTC was implemented in Western Canada in four diverse facilities that varied in terms of ownership, leadership models, bed size and geography. Two palliative ‘link nurses’ were hired for 1 day a week at each site over a two-year time frame to facilitate a PAC and support education and training.

This paper evaluates the challenges with embedding the PAC-QI into LTC, from the perspectives of the direct care, or front-line team members. Sixteen focus groups were undertaken with 80 front-line workers who were predominantly RNs/LPNs (n = 25), or Health Care Aides (HCAs; n = 32). A total of 23 other individuals from the ranks of dieticians, social workers, recreation and rehabilitation therapists and activity coordinators also participated. Each focus group was taped and transcribed and thematically analyzed by research team members to develop and consolidate the findings related to challenges with embedding the PAC.

Results

Thematic analyses revealed that front-line workers are deeply committed to providing high quality PAC, but face challenges related to longstanding conditions in LTC notably, staff shortages, and perceived lack of time for providing compassionate care. The environment is also characterized by diverse views on what a PAC is, and when it should be applied. Our research suggests that integrated, holistic and sustainable PAC depends upon access to adequate resources for education, training for front-line care workers, and supportive leadership.

Conclusions

The urgent need for integrated PAC models in LTC has been accentuated by the current COVID-19 pandemic. Consequently, it is more imperative than ever before to move forwards with such models in order to promote quality of care and quality of life for residents and families, and to support job satisfaction for essential care workers.

Haynes A, Ford J, Beck S, Haljan GJ. Sources of Distress for Residents With Chronic Critical Illness and Ventilator Dependence in Long-Term Care

Limited understanding of the psychological challenges experienced by individuals with chronic critical illness hampers efforts to deliver quality care. We used an interpretive description approach to explore sources of distress for individuals with chronic critical illness in residential care, wherein we interviewed six residents, 11 family members, and 21 staff. Rather than discuss physical symptoms, sources of distress for residents were connected to feeling as though they were a patient receiving medical care as opposed to an individual living in their home. The tension between medical care and the unmet need for a sense of home was related to care beyond the physical being overlooked, being dependent on others but feeling neglected, frustration with limited choice and participation in decision making, and feeling sad and alone. Efforts to refine health care for individuals with chronic critical illness must foster a sense of home while ensuring individuals feel safe and supported to make decisions.

A mixed-method evaluation of a volunteer navigation intervention for older persons living with chronic illness (Nav-CARE): findings from a knowledge translation study

Background

Volunteer navigation is an innovative way to help older persons get connected to resources in their community that they may not know about or have difficulty accessing. Nav-CARE is an intervention in which volunteers, who are trained in navigation, provide services for older persons living at home with chronic illness to improve their quality of life. The goal of this study was to evaluate the impact of Nav-CARE on volunteers, older persons, and family participating across eight Canadian sites.

Methods

Nav-CARE was implemented using a knowledge translation approach in eight sites using a 12- or 18-month intervention period. A mixed method evaluation was used to understand the outcomes upon older person engagement; volunteer self-efficacy; and older person, family, and volunteer quality of life and satisfaction with the intervention.

Results

Older persons and family were highly satisfied with the intervention, citing benefits of social connection and support, help with negotiating the social aspects of healthcare, access to cost-effective resources, and family respite. They were less satisfied with the practical help available for transportation and errands. Older persons self-reported knowledge of the services available to them and confidence in making decisions about their healthcare showed statistically significant improvements (P < .05) over 12–18 months. Volunteers reported satisfaction with their role, particularly as it related to building relationships over time, and good self-efficacy. Volunteer attrition was a result of not recruiting older persons in a timely manner. There was no statistically significant improvement in quality of life for older persons, family or volunteers from baseline to study completion.

Conclusions

Findings from this study support a developing body of evidence showing the contributions volunteers make to enhanced older person and family well-being in the context of chronic illness. Statistically significant improvements were documented in aspects of client engagement. However, there were no statistically significant improvements in quality of life scores even though qualitative data illustrated very specific positive outcomes of the intervention. Similar findings in other volunteer-led intervention studies raise the question of whether there is a need for targeted volunteer-sensitive outcome measures.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12904-020-00666-2.

Analysis of Spanish nursing students' knowledge in palliative care. An online survey in five colleges

Along their professional career, nurses can find patients who require palliative care (PC). It is necessary to have at least a basic education in this area, that should be acquired during their university education. The objective of this descriptive online-survey set in five nursing Colleges was to analyze Spanish nursing students' knowledge in PC, offering an image of the status of education in PC. 619 students took an online questionnaire with the Spanish version of the Palliative Care Quiz for Nurses (PCQN-SV), which also collected information about their education in the field of PC. Univariate and bivariate analyses were performed, and a predictive binary logistic regression model was developed. Students obtained an average 45.65% of right answers in PCQN-SV, with differences related to the college and academic year in which they were enrolled and to their education in PC. In the regression model having theoretical education in PC (OR = 1.70) and academic year (OR = 1.35) showed to be both predictors of getting a result in PCQN-SV over 45% of correct answers. This study showed that Spanish nursing students have a medium-low level of knowledge in PC, and it also supports the need to develop a common framework for nurses' education in PC.

Using the technology acceptance model to explore health provider and administrator perceptions of the usefulness and ease of using technology in palliative care

BACKGROUND

Studies have shown that telehealth applications in palliative care are feasible, can improve quality of care, and reduce costs but few studies have focused on user acceptance of current technology applications in palliative care. Furthermore, the perspectives of health administrators have not been explored in palliative care and yet they are often heavily involved, alongside providers, in the coordination and use of health technologies. The study aim was to explore both health care provider and administrator perceptions regarding the usefulness and ease of using technology in palliative care.

METHODS

The Technology Acceptance Model (TAM) was used as the guiding theoretical framework to provide insight into two key determinants that influence user acceptance of technology (perceived usefulness and ease of use). Semi-structured interviews (n = 18) with health providers and administrators with experience coordinating or using technology in palliative care explored the usefulness of technologies in palliative care and recommendations to support adoption. Interview data were analyzed using inductive thematic analysis to identify common, meaningful themes.

RESULTS

Four themes were identified; themes related to perceived usefulness were: enabling remote connection and information-sharing platform. Themes surrounding ease of use included: integration with existing IT systems and user-friendly with ready access to technical support. Telehealth can enable remote connection between patients and providers to help address insufficiencies in the current palliative care environment. Telehealth, as an information sharing platform, could support the coordination and collaboration of interdisciplinary providers caring for patients with palliative needs. However, health technologies need to passively integrate with existing IT systems to enhance providers' workflow and productivity. User-friendliness with ready access to technical support was considered especially important in palliative care as patients often experience diminished function.

CONCLUSION

Participants' perspectives of technology acceptance in palliative care were largely dependent on their potential to help address major challenges in the field without imposing significant burden on providers and patients.

Implementing volunteer-navigation for older persons with advanced chronic illness (Nav-CARE): a knowledge to action study

BACKGROUND

Nav-CARE is a volunteer-led intervention designed to build upon strategic directions in palliative care: a palliative approach to care, a public health/compassionate community approach to care, and enhancing the capacity of volunteerism. Nav-CARE uses specially trained volunteers to provide lay navigation for older persons and family living at home with advanced chronic illness. The goal of this study was to better understand the implementation factors that influenced the utilization of Nav-CARE in eight diverse Canadian contexts.

METHODS

This was a Knowledge to Action study using the planned action cycle for Nav-CARE developed through previous studies. Participants were eight community-based hospice societies located in diverse geographic contexts and with diverse capacities. Implementation data was collected at baseline, midpoint, and endpoint using qualitative individual and group interviews. Field notes of all interactions with study sites were also used as part of the data set. Data was analyzed using qualitative descriptive techniques. The study received ethical approval from three university behavioural review boards. All participants provided written consent.

RESULTS

At baseline, stakeholders perceived Nav-CARE to be a good fit with the strategic directions of their organization by providing early palliative support, by facilitating outreach into the community and by changing the public perception of palliative care. The contextual factors that determined the ease with which Nav-CARE was implemented included the volunteer coordinator champion, organizational capacity and connection, the ability to successfully recruit older persons, and the adequacy of volunteer preparation and mentorship.

CONCLUSIONS

This study highlighted the importance of community-based champions for the success of volunteer-led initiatives and the critical need for support and mentorship for both volunteers and those who lead them. Further, although the underutilization of hospice has been widely recognized, it is vital to recognize the limitations of their capacity. New initiatives such as Nav-CARE, which are designed to enhance their contributions to palliative care, need to be accompanied by adequate resources. Finally, this study illustrated the need to think carefully about the language and role of hospice societies as palliative care moves toward a public health approach to care.

Restoring trust: COVID-19 and the future of long-term care in Canada

The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Task Force established a series of working groups to rapidly develop policy briefings, with the objective of supporting policy makers with evidence to inform their decisions. This paper reports the findings of the COVID-19 Long-Term Care (LTC) working group addressing a preferred future for LTC in Canada, with a specific focus on COVID-19 and the LTC workforce. First, the report addresses the research context and policy environment in Canada’s LTC sector before COVID-19 and then summarizes the existing knowledge base for integrated solutions to challenges that exist in the LTC sector. Second, the report outlines vulnerabilities exposed because of COVID-19, including deficiencies in the LTC sector that contributed to the magnitude of the COVID-19 crisis. This section focuses especially on the characteristics of older adults living in nursing homes, their caregivers, and the physical environment of nursing homes as important contributors to the COVID-19 crisis. Finally, the report articulates principles for action and nine recommendations for action to help solve the workforce crisis in nursing homes.

Critical nursing and health care aide behaviors in care of the nursing home resident dying with dementia

Background

With the aging of the population, dying with dementia will become one of the most common ways in which older adults will end their final years of life, particularly for those living in a nursing home. Though individuals living with dementia have complex care needs and would benefit from a palliative approach to care, they have traditionally not been recipients of such care. An important aspect of determining quality in end-of-life care is the identification of expert practices, processes or behaviors that may help achieve this care. However, for those living with dementia in nursing homes, we have a limited understanding of how to best support expert end of life care. To redress this gap in knowledge, the purpose of this study was to examine and describe expert care of the individual with dementia approaching death from the perspective of nurses and health care aides (HCAs) identified by their peers as having special expertise in caring for this population.

Methods

A qualitative research design known as Interpretative Description was used to conduct the study. Expert nurses and HCAs were identified through a two-phase nomination process. Individual semi-structured interviews were conducted with consenting participants. Data were analyzed using constant comparative analysis to determine the key critical behaviors.

Results

Analysis of data collected from expert nurses (n = 8) and HCAs (n = 7) revealed six critical behaviors when caring for residents dying with dementia. All nurses and HCAs unanimously endorsed that the overarching goal of care is similar for all residents who are actively dying; to achieve comfort. The six critical behaviors in caring for residents dying with dementia included: 1) recognizing and responding to changes in a resident’s pattern of behavior; 2) attending to the person; 3) working with the family; 4) engaging with others; 5) responding after the death has occurred; and 6) having a positive attitude toward care of the dying.

Conclusions

The critical behaviors described by nurses and HCAs in this study provides emerging evidence of best practices in care of those with dementia and their families, particularly near the end of life within the nursing home setting.

Medically Assisted Dying in Canada: "Beautiful Death" Is Transforming Nurses' Experiences of Suffering

BACKGROUND

Nurses witness pain and distress up close and consequently experience their own suffering. A narrative study of Canadian nurses' participating in medical assistance in dying found nurses' previous witnessing of unresolved end-of-life suffering has shaped their acceptance of medical assistance in dying. Little is known about the impact of participating in medically assisted dying on nurses' suffering.

PURPOSE

To explore how nurses' overall experience of suffering is shaped by participating in medical assistance in dying.

METHODS

Qualitative secondary analysis using narrative inquiry and thematic analysis.

RESULTS

Nurses' narratives are chronologically organized addressing experiences of suffering before medical assistance in dying was a legal option and after its implementation. An overarching narrative before the availability of medical assistance in dying is (1) a culture of nurses' taken-for-granted suffering: feeling terrible. After medical assistance in dying, two key narratives describe (2) transformational feelings of a beautiful death and (3) residual discomfort. Nurses found their suffering transformed when participating in medical assistance in dying; end-of-life care was satisfying and gratifying. And yet, unanswered questions due to worries of becoming desensitized and ongoing deeper questioning remain.

CONCLUSIONS

Participating in medical assistance in dying has positively impacted nurses and starkly contrasts their previous experiences caring for those with unbearable suffering. Further research is needed to explore becoming desensitized and long-term emotional impact for nurses.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Barriers to Staff Involvement in End-of-Life Decision-Making for Long-Term Care Residents with Dementia

ABSTRACTAlthough providing direct care to residents with dementia, long-term care (LTC) home staff of registered nurses', registered practical nurses', and personal support workers' involvement in end-of-life decision-making is rarely acknowledged. The purpose of this study was to examine barriers and facilitators to LTC home staff involvement in end-of-life decision-making for people with advanced dementia. We report on the barriers to staff involvement in decision-making. Using an interpretive descriptive design, four major barriers to staff involvement in decision-making were identified: (a) the predominance of a biomedical model of care; (b) a varied understanding of a palliative approach; (c) challenging relationships with families; and (d) a discomfort with discussing death. Findings suggest that the predominant biomedical model in LTC homes, while important, must be imbued with a philosophy that emphasizes relationships among residents with dementia, family and staff.

Enabling At-Homeness for Older People With Life-Limiting Conditions: A Participant Observation Study From Nursing Homes

At-homeness, as an aspect of well-being, can be experienced despite living with life-limiting conditions and needs for a palliative approach to care. In nursing homes, older residents with life-limiting conditions face losses and changes which could influence their experience of at-homeness. The aim of this study was to explore how nursing staff enable at-homeness for residents with life-limiting conditions. Interpretive description was employed as the design using data from participant observations and formal and informal interviews related to nursing care situations. The strategies found to be used to enable at-homeness comprising nursing staff presenting themselves as reliable, respecting the resident's integrity, being responsive to the resident's needs, collaborating with the resident in decision-making, and through nurturing comforting relationships. The result on how to enable at-homeness could be used as strategies for a person-centered palliative approach in the care for residents in nursing homes.

Living with dying: A narrative inquiry of people with chronic kidney disease and their family members

Aims

To describe how people diagnosed with chronic kidney disease and their family members describe uncertainty related to impending death.

Background

There has been little research about the experiences of people with chronic kidney disease and their family members as they near the end‐of‐life. We need to understand these experiences to give holistic person‐centred care.

Design

A narrative enquiry was undertaken using a social constructionist perspective.

Methods

Data were collected in two in‐depth interviews, approximately 3–4 months apart, followed by a telephone follow‐up 2–3 months later.

Results

Eleven people with advanced chronic kidney disease and nine family members/significant others participated. For both participants in the dyad, a number of key themes/storylines were identified. These included recognition that: @life has a boundary, living on the edge, I'm not afraid to die but… and remembering loss and death experiences@.

Conclusions

This enquiry illuminated four key storylines of about death and dying with advanced chronic kidney disease for people with the illness and their family members. Discussion about past experiences with illness, loss, death, and dying can give an entry for discussion about end‐of‐life. The person with illness and family members often held very similar perceptions and desires, but healthcare professionals’ contributions to understanding of the experience were not mentioned. Implications for clinicians include attending to peoples’ awareness of death as a distinct opportunity, listening attentively and posing questions that genuinely invite concerns and wishes about end–of‐life and living well.

Bereaved family members' perceptions of the quality of end-of-life care across four types of inpatient care settings

BACKGROUND

The aims of this study were to gain a better understanding of how bereaved family members perceive the quality of EOL care by comparing their satisfaction with quality of end-of-life care across four different settings and by additionally examining the extent to which demographic characteristics and psychological variables (resilience, optimism, grief) explain variation in satisfaction.

METHODS

A cross-sectional mail-out survey was conducted of bereaved family members of patients who had died in extended care units (n = 63), intensive care units (n = 30), medical care units (n = 140) and palliative care units (n = 155). 1254 death records were screened and 712 bereaved family caregivers were identified as eligible, of which 558 (who were initially contacted by mail and then followed up by phone) agreed to receive a questionnaire and 388 returned a completed questionnaire (response rate of 70%). Measures included satisfaction with end-of-life care (CANHELP- Canadian Health Care Evaluation Project - family caregiver bereavement version; scores range from 0 = not at all satisfied to 5 = completely satisfied), grief (Texas Revised Inventory of Grief (TRIG)), optimism (Life Orientation Test - Revised) and resilience (The Resilience Scale). ANCOVA and multivariate linear regression were used to analyze the data.

RESULTS

Family members experienced significantly lower satisfaction in MCU (mean = 3.69) relative to other settings (means of 3.90 [MCU], 4.14 [ICU], and 4.00 [PCU]; F (3371) = 8.30, p = .000). Statistically significant differences were also observed for CANHELP subscales of "doctor and nurse care", "illness management", "health services" and "communication". The regression model explained 18.9% of the variance in the CANHELP total scale, and between 11.8% and 27.8% of the variance in the subscales. Explained variance in the CANHELP total score was attributable to the setting of care and psychological characteristics of family members (44%), in particular resilience.

CONCLUSION

Findings suggest room for improvement across all settings of care, but improving quality in acute care and palliative care should be a priority. Resiliency appears to be an important psychological characteristic in influencing how family members appraise care quality and point to possible sites for targeted intervention.

Patient-experienced burden of treatment in patients with multimorbidity - A systematic review of qualitative data

Objective

To synthesize existing qualitative literature on patient-experienced burden of treatment in multimorbid patients.

Methods

A literature search identified available qualitative studies on the topic of burden of treatment in multimorbidity and meta-ethnography was applied as method. The authors’ original findings were preserved, but also synthesized to new interpretations to investigate the concept of the burden of treatment using the Cumulative Complexity Model.

Results

Nine qualitative studies were identified. The majority of the 1367 participants from 34 different countries were multimorbid. The treatment burden components, experienced by patients, were identified for each study. The components financial burden, lack of knowledge, diet and exercise, medication burden and frequent healthcare reminding patients of their health problem were found to attract additional attention from the multimorbid patients. In studies conducted in the US and Australia the financial burden and the time and travel burden were found most straining to patients with deprived socioeconomic status.

The burden of treatment was found to be a complex concept consisting of many different components and factors interacting with each other. The size of the burden was associated to the workload of demands (number of conditions, number of medications and health status), the capacity (cognitive, physical and financial resources, educational level, cultural background, age, gender and employment conditions) and the context (structure of healthcare and social support).

Patients seem to use strategies such as prioritizing between treatments to diminish the workload and mobilizing and coordinating resources to improve their ability to manage the burden of treatment. They try to routinize and integrate the treatment into their daily lives, which might be a way to maintain the balance between workload and capacity.

Conclusions

Healthcare providers need to increase the focus on minimizing multimorbid patients’ burden of treatment. Findings in this review suggest that the weight of the burden needs to be established in the individual patient and components of the burden must be identified.