Unexpected death in palliative care: what to expect when you are not expecting

Factors related to advance directives completion among cancer patients: a systematic review

INTRODUCTION

Advance directives (ADs) has recently been considered as an important component of palliative care for patients with advanced cancer and is a legally binding directive regarding a person's future medical care. It is used when a person is unable to participate in the decision-making process about their own care. Therefore, the present systematic review investigated the factors related to ADs from the perspective of cancer patients.

METHODS

A systematic review study was searched in four scientific databases: PubMed, Medline, Scopus, Web of Science, and ProQuest using with related keywords and without date restrictions. The quality of the studies was assessed using the Hawker criterion. The research papers were analyzed as directed content analysis based on the theory of planned behavior.

RESULTS

Out of 5900 research papers found, 22 were included in the study. The perspectives of 9061 cancer patients were investigated, of whom 4347 were men and 4714 were women. The mean ± SD of the patients' age was 62.04 ± 6.44. According to TPB, factors affecting ADs were categorized into four categories, including attitude, subjective norm, perceived behavioral control, and external factors affecting the model. The attitude category includes two subcategories: "Lack of knowledge of the ADs concept" and "Previous experience of the disease", the subjective norm category includes three subcategories: "Social support and interaction with family", "Respecting the patient's wishes" and "EOL care choices". Also, the category of perceived control behavior was categorized into two sub-categories: "Decision-making" and "Access to the healthcare system", as well as external factors affecting the model, including "socio-demographic characteristics".

CONCLUSION

The studies indicate that attention to EOL care and the wishes of patients regarding receiving medical care and preservation of human dignity, the importance of facilitating open communication between patients and their families, and different perspectives on providing information, communicating bad news and making decisions require culturally sensitive approaches. Finally, the training of cancer care professionals in the palliative care practice, promoting the participation of health care professionals in ADs activities and creating an AD-positive attitude should be strongly encouraged.

Advance Care Planning in Indonesia: Current state and future prospects

Indonesia is a low-middle income country in Southeast Asia, as well as the world's fourth most populous and largest archipelagic nation. Indonesia has approximately 1,300 ethnic groups that speak 800 different languages and are typically collectivist and religiously devout. With an aging population and an increasing number of cancer patients, palliative care in the country remains scarcely available, disproportionally distributed, and underfunded. All of these factors (economic level, geographical and cultural landscapes, and palliative care level of development) pose a considerable impact on the adoption of advance care planning in Indonesia. Nonetheless, recent advocacy initiatives promise some hopes in advance care planning in Indonesia. Furthermore, local studies suggested opportunities to implement advance care planning, particularly through capacity building and a culturally sensitive approach to it. This article describes the present situation of advance care planning in Indonesia, including its challenges and opportunities.

Prediction of Survival in Patients with Advanced Cancer: A Narrative Review and Future Research Priorities

This paper aimed to summarize the current situation of prognostication for patients with an expected survival of weeks or months, and to clarify future research priorities. Prognostic information is essential for patients, their families, and medical professionals to make end-of-life decisions. The clinician's prediction of survival is often used, but this may be inaccurate and optimistic. Many prognostic tools, such as the Palliative Performance Scale, Palliative Prognostic Index, Palliative Prognostic Score, and Prognosis in Palliative Care Study, have been developed and validated to reduce the inaccuracy of the clinician's prediction of survival. To date, there is no consensus on the most appropriate method of comparing tools that use different formats to predict survival. Therefore, the feasibility of using prognostic scales in clinical practice and the information wanted by the end users can determine the appropriate prognostic tool to use. We propose four major themes for further prognostication research: (1) functional prognosis, (2) outcomes of prognostic communication, (3) artificial intelligence, and (4) education for clinicians.

What roles does physical activity play following the death of a parent as a young person? A qualitative investigation

BACKGROUND

Physical activity benefits physical and mental health. However, limited research investigates if physical activity can improve outcomes from the grieving process following the death of a parent.

METHODS

Semi-structured interviews were conducted with 14 individuals (n = 8 female; age M = 31.2 years), who had experienced the death of a parent when they were aged between 10 and 24 years old, using retrospective recall. Data were analysed inductively using thematic analysis.

RESULTS

Six themes were identified. Physical activity was seen as; 1) 'Therapeutic'; providing an 2) 'Emotional Outlet' and created a strong sense of 3) 'Social Support'. Alongside it 4) 'Builds Confidence', and led to 5) 'Finding Yourself' and 6) 'Improved Health and wellbeing' (physical and psychological).

CONCLUSION

Physical activity has the potential to provide positive experiences following a parental bereavement. It can provide a sense of freedom and was seen to alleviate grief outcomes, build resilience, enable social support and create a stronger sense of self. Bereavement support services for young people who have experienced death of a parent should consider physical activity as a viable intervention to support the grieving process.

Exploring Risk Factors of Unexpected Death, Using Palliative Care Outcomes Collaboration (PCOC) Measures, among Terminal Patients Receiving Palliative Care in Taiwan

Palliative care has the ability to relieve both physical discomfort and psychological distress in terminally ill patients. However, unexpected death may still occur in palliative care settings. This study aimed to utilize Palliative Care Outcomes Collaboration (PCOC) data to better determine any associated factors which may surround unexpected death in palliative care settings. Data were extracted from the PCOC database by the palliative care team within Taichung Veterans General Hospital (TCVGH). Data of deceased patients were extracted during the period from January 2021 to December 2021 from multiple palliative care settings. The deaths of patients whose last recorded palliative phase was 1-3 were defined as unexpected. A total of 280 deceased patients were included, with mean age at death being 67.73, 61% being male, and 83.2% cancer patients. We discovered that shortness of breath, as assessed by the Symptom Assessment Scale (SAS), decreased risk of unexpected death (OR: 0.91, 95% CI: 0.84-0.98), while impending death discharge (OR: 3.93, 95% CI: 1.20-12.94) and a higher Australia-modified Karnofsky performance status (AKPS) score (OR: 1.15, 95% CI: 1.10-1.21) were associated with unexpected death. Thus, medical staff must inform the family of patients early on regarding any risk factors surrounding unexpected death to help everyone involved be prepared in advance.

Family involvement in advance care planning for people living with advanced cancer: A systematic mixed-methods review

BACKGROUND

Advance care planning is important for people with advanced cancer. Family involvement in advance care planning may be instrumental to achieving goal-concordant care since they frequently become surrogate decision-makers.

AIM

To examine components, contexts, effects and linkages with intended outcomes of involving family members in advance care planning.

DESIGN

A mixed-methods systematic review, in which quantitative and qualitative data were extracted and synthesised using thematic synthesis leading to a logic model. Prospectively registered on PROSPERO (CRD42020208143).

DATA SOURCES

Primary quantitative and qualitative research regarding family-involved advance care planning for people with advanced cancer were identified using Medline, Embase, PsycINFO and CINAHL from inception to September 2020. Quality appraisal was performed with 'QualSyst'.

RESULTS

Fourteen articles were included. The synthesis identified perceptions of individuals and family members concerning family involvement in advance care planning and presents components for family-integrated advance care planning intervention. The logic model includes (i) addressing family members' concerns and emotions and (ii) facilitating communication between individuals and family members which are distinctive when healthcare professionals engage with individuals as well as family members.

CONCLUSIONS

This review provides a comprehensive understanding of family involvement in advance care planning and could inform its assessment and implementation in clinical practice. The number of included articles was limited. Therefore future research must focus on family integration and exploration of stakeholders' perceptions to identify additional components and linkages between them within family-integrated advance care planning.

Oncology palliative care: access barriers: bibliometric study

OBJECTIVE

To perform a bibliometric analysis of studies that evaluated the barriers to access to cancer palliative care (PC).

METHODS

This was a bibliometric review using MEDLINE; EMBASE; Web Of Science; LILACS and the Cochrane Library. A search was conducted with the terms Barriers, Palliative Care and Cancer. Articles whose objectives targeted barriers to access to PC were considered, regardless of the year of publication. The setting is articles published from 1987 to 2020.

RESULTS

A total of 6158 articles were identified, of which 217 were eligible for analysis. The USA and UK being the countries with the largest number of articles on the subject (n=101, n=18, respectively). After expert analysis, the barriers were grouped into nine categories.

CONCLUSIONS

Barriers related to symptom control were identified in 19% of the eligible articles, along with barriers related to health, which with 24% of occurrence in the articles, were the most frequently cited barriers. Countries which have implemented PC for some time were those with the greatest number of publications and in journals with the highest impact factors. Cross-sectional study design continues to be the most frequently used in publications.

Deaths in critical care and hospice-prevalence, trends, influences: a national decedent cohort study

OBJECTIVES

End-of-life and bereavement care support services differ in critical care and inpatient hospice settings. There are limited population-level data comparing deaths in these two locations. We aimed to compare the characteristics of people who die in critical care units and in hospices, identify factors associated with place of death and report 12-year trends in Scotland.

METHODS

We undertook a cohort study of decedents aged ≥16 years in Scotland (2005-2017). Location of death was identified from linkage to the Scottish Intensive Care Society Audit Group database and National Records of Scotland Death Records. We developed a multinomial logistic regression model to identify factors independently associated with location of death.

RESULTS

There were 710 829 deaths in Scotland, of which 36 316 (5.1%) occurred in critical care units and 42 988 (6.1%) in hospices. As a proportion of acute hospital deaths, critical care deaths increased from 8.0% to 11.2%. Approximately one in eight deaths in those aged under 40 years occurred in critical care. Factors independently associated with hospice death included living in less deprived areas, cancer as the cause of death and presence of comorbidities. In contrast, liver disease and accidents as the cause of death and absence of comorbidities were associated with death in critical care.

CONCLUSIONS

Similar proportions of deaths in Scotland occur in critical care units and hospices. Given the younger age profile and unexpected nature of deaths occurring in critical care units, there is a need for a specific focus on end-of-life and bereavement support services in critical care units.

Dying Alone during a Pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented experience that has had profound impact and consequences for health care providers, visitation policies, and procedures. Hospitals and health care facilities were forced to implement changes to visitation policies, in an effort, to minimize transmission of the virus, which unfortunately had negative impact on patients' and family members' well-being as well as moral distress for the staff. Objectives: We present here a case illustration of the impacts of such a response to the pandemic situation at our institution, including challenges for uniformly implementing such a change along with suggestions to support patients during these difficult times. Conclusion: Health care facilities should make efforts to maintain balance between safety precautions and minimizing potential negative impacts on patients, families, and staff by implementing innovative measures to support ongoing communication and access to family support.

Incidence and associated factors of sudden unexpected death in advanced cancer patients: A multicenter prospective cohort study

Purpose

A sudden unexpected death has significant negative impacts on patients, family caregivers, and medical staff in hospice/palliative care. This study aimed to clarify the incidence and associated factors of sudden unexpected death according to four definitions in advanced cancer patients.

Methods

We performed a prospective cohort study in 23 inpatient hospices/palliative care units in Japan. Advanced cancer patients aged ≥18 years who were admitted to inpatient hospices/palliative care units were included. The incidence and associated factors of sudden unexpected death were evaluated in all enrolled patients according to four definitions: (a) rapid decline death, defined as a sudden death preceded by functional decline over 1–2 days; (b) surprise death, defined if the primary responsible palliative care physician answered “yes” to the question, “Were you surprised by the timing of the death?”; (c) unexpected death, defined as a death that occurred earlier than the physicians had anticipated; and (d) performance status (PS)‐defined sudden death, defined as a death that occurred within 1 week of functional status assessment with an Australia‐modified Karnofsky PS ≥50.

Results

Among 1896 patients, the incidence of rapid decline death was the highest (30‐day cumulative incidence: 16.8%, 95% CI: 14.8–19.0%), followed by surprise death (9.6%, 8.1–11.4%), unexpected death (9.0%, 7.5–10.8%), and PS‐defined sudden death (6.4%, 5.2–8.0%). Male sex, liver metastasis, dyspnea, malignant skin lesion, and fluid retention were significantly associated with the occurrence of sudden unexpected death.

Conclusion

Sudden unexpected death is not uncommon even in inpatient hospices/palliative care units, with range of 6.4–16.8% according to the different definitions.

Patient with respiratory distress, facial oedema and refractory hypokalaemia

Small cell lung carcinoma, when associated with co-occurrence of complications such as paraneoplastic syndrome and superior vena cava syndrome, poses a greater management challenge to the clinical team. We report a 56-year-old man who was eventually diagnosed with stage III small cell lung carcinoma, presenting with respiratory distress, facial and upper body oedema, proximal muscle weakness, hypokalaemia, new-onset hypertension and hyperglycaemia. His medical management was complicated by associated superior vena cava syndrome and Cushing’s syndrome leading to refractory hypokalemia, immunosuppression and depression. Although the patient improved clinically and biochemically with the chemotherapy and other treatments, the development of neutropenic pneumonia led to his demise. This case highlights the importance of a multidisciplinary approach to achieve better patient care and the need for good clinical vigilance to identify possible humoral manifestations of aggressive malignancies such as small cell carcinoma of the lung to assist their early detection.

Self-care while undertaking qualitative nursing research

BACKGROUND

Nursing research is usually carried out by registered nurses with some experience of practice. However, nurses may find that the role of the nurse researcher is very different from that of the practising clinical nurse and has its own challenges.

AIM

To explore the differences between the two roles and offer some guidance to nurses carrying out qualitative research, particularly research into sensitive topics.

DISCUSSION

Nurses need to be aware of various issues that could affect their ability to carry out nursing research and be emotionally traumatic.

CONCLUSION

There is a general need for greater awareness about the potential risks of carrying out qualitative research into sensitive topics.

IMPLICATIONS FOR PRACTICE

Nurse researchers must consider self-care when planning a research project, assessing their role, personality, background, personal experiences and stress triggers, and ensuring peer and supervisory support, reflection and a healthy lifestyle.

Dealing with prognostic uncertainty: the role of prognostic models and websites for patients with advanced cancer

PURPOSE OF REVIEW

To provide an updated overview of prognostic models in advanced cancer and highlight the role of prognostic calculators.

RECENT FINDINGS

In the advanced cancer setting, many important healthcare decisions are driven by a patient's prognosis. However, there is much uncertainty in formulating prognosis, particularly in the era of novel cancer therapeutics. Multiple prognostic models have been validated for patients seen by palliative care and have a life expectancy of a few months or less, such as the Palliative Performance Scale, Palliative Prognostic Score, Palliative Prognostic Index, Objective Prognostic Score, and Prognosis in Palliative Care Study Predictor. However, these models are seldom used in clinical practice because of challenges related to limited accuracy when applied individually and difficulties with model selection, computation, and interpretation. Online prognostic calculators emerge as tools to facilitate knowledge translation by overcoming the above challenges. For example, www.predictsurvival.com provides the output for seven prognostic indexes simultaneously based on 11 variables.

SUMMARY

Prognostic models and prognostic websites are currently available to augment prognostication in the advanced cancer setting. Further studies are needed to examine their impact on prognostic accuracy, confidence, and clinical outcomes.

Patient deaths and medical residents: an Asian perspective

OBJECTIVES

Death is a significant event that affects healthcare providers emotionally. We aimed to determine internal medicine (IM) and paediatric (PD) residents' responses and the impact on the residents following patient deaths, and to compare any differences between IM and PD residents. We also aimed to determine whether sufficient resources and measures were in place to support residents through their grief process.

METHODS

This is a single-centre, cross-sectional study involving residents from IM and PD programmes from an academic tertiary hospital in Singapore. The residents completed a questionnaire regarding their responses and emotions after experiencing patient deaths.

RESULTS

A total of 122 residents (85 IM and 37 PD, equally distributed between year 1 to year 4 of residency training) participated, with 100% response rate. Only half (57%) felt they would be comfortable treating a dying patient and 66.4% reported feeling sad following their patient's death. Most (79.5%) were not aware of support resources that were available and 82% agreed that formal bereavement training should be included in the residency curriculum. PD residents had more negative symptoms than IM residents, with poor concentration (PD 35.1% vs IM 16.5%, p=0.02) and lethargy (PD 35.1% vs IM 9.4%, p<0.01) being the most common.

CONCLUSION

In our Asian context, residents are negatively affected by patient deaths, especially the PD residents. There is a need to incorporate relevant bereavement training for all residents.

Undergraduate nursing students' participation in pre-hospital first aid practice with ambulances in China: A qualitative study

OBJECTIVES

The aim of this study is to understand the feelings and experiences of nursing undergraduates who participate in pre-hospital first aid and to explore the training programme of pre-hospital first aid for nursing undergraduates. The main objective is to provide a reference for the reform of pre-hospital first aid teaching in undergraduate colleges.

METHODS

Semi-structured interviews were conducted with 16 nursing undergraduates who had participated in pre-hospital first aid in an ambulance from a teaching hospital in Hunan, China. The interview data were transcribed, and Colaizzi's seven-step method was used for subject analysis.

RESULTS

The experiences of undergraduate nursing interns can be summarized into five themes: helplessness and fear of death, uncertainty of unknown events, satisfaction with self-improvement, need for professional competence, and the perception of a gap in pre-hospital emergency resources.

CONCLUSIONS

Nursing colleges and teaching hospitals should pay attention to death education and pre-hospital first aid training. Teachers should be able to apply situational teaching methods to pre-hospital first-aid teaching and should focus on cultivating the comprehensive abilities of nursing students. At the same time, schools and teaching hospitals should also strengthen the cultivation of professional identity during pre-hospital first aid practice to reduce the rate of nursing personnel turnover. It's very important to supplement and retain professional nurses for the pre-hospital first aid.

Grief After Euthanasia and Physician-Assisted Suicide

Background: Several countries have regulated euthanasia and physician-assisted suicide (PAS). Research has looked at the experiences of patients, family, and professionals. However, little is known of the effects on bereaved individuals. Aims: We aimed to assess (a) what is known about the grief and mental health of people bereaved by euthanasia or PAS and (b) the quality of the research. Method: Systematic review according to PRISMA guidelines with searches in Cinahl, Embase, PsycINFO, Pubmed, and Scopus. Results: The searches identified 10 articles (eight studies), and the study quality was fair. People bereaved by euthanasia/PAS generally had similar or lower scores on measures of disordered grief, mental health, and posttraumatic stress compared with those who died naturally. Lack of social support and secrecy may compound their grief. Being involved in the decision-making process and having the feeling of honoring the deceased's will may facilitate their grief. Limitations: Studies used self-reports from non-random self-selected participants, were retrospective, and were conducted in only three countries. Conclusion: There is little evidence of increased risk of adverse grief or mental health outcomes in people bereaved by euthanasia/PAS. As more countries legalize assisted dying, high-quality studies of the factors that may hinder or facilitate the grief process are needed.

Toward a Conceptual Model of Affective Predictions in Palliative Care

CONTEXT

Being diagnosed with cancer often forces patients and families to make difficult medical decisions. How patients think they and others will feel in the future, termed affective predictions, may influence these decisions. These affective predictions are often biased, which may contribute to suboptimal care outcomes by influencing decisions related to palliative care and advance care planning.

OBJECTIVES

This study aimed to translate perspectives from the decision sciences to inform future research about when and how affective predictions may influence decisions about palliative care and advance care planning.

METHODS

A systematic search of two databases to evaluate the extent to which affective predictions have been examined in the palliative care and advance care planning context yielded 35 relevant articles. Over half utilized qualitative methodologies (n = 21). Most studies were conducted in the U.S. (n = 12), Canada (n = 7), or European countries (n = 10). Study contexts included end of life (n = 10), early treatment decisions (n = 10), pain and symptom management (n = 7), and patient-provider communication (n = 6). The affective processes of patients (n = 20), caregivers (n = 16), and/or providers (n = 12) were examined.

RESULTS

Three features of the palliative care and advance care planning context may contribute to biased affective predictions: 1) early treatment decisions are made under heightened emotional states and with insufficient information; 2) palliative care decisions influence life domains beyond physical health; and 3) palliative care decisions involve multiple people.

CONCLUSION

Biases in affective predictions may serve as a barrier to optimal palliative care delivery. Predictions are complicated by intense emotions, inadequate prognostic information, involvement of many individuals, and cancer's effect on non-health life domains. Applying decision science frameworks may generate insights about affective predictions that can be harnessed to solve challenges associated with optimal delivery of palliative care.

When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer

OBJECTIVE

To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions.

METHODS

Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life.

RESULTS

Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude.

CONCLUSION

Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life.

PRACTICE IMPLICATIONS

Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.

Caregivers' perceptions of illness severity and end of life service utilization in advanced heart failure

OBJECTIVES

To assess perceptions of illness severity and terminality in caregivers of advanced heart failure (HF) patients and how these perceptions influence utilization of palliative care and end-of life services.

BACKGROUND

HF is a terminal disease; yet patients and caregivers do not understand the severity of HF or acknowledge disease terminality.

METHODS

This study was conducted using a qualitative design with in-depth interviews and content analysis.

RESULTS

Most caregivers did not understand the severity of HF (68%) or disease terminality (67%). Patients were more likely to receive services when their caregivers expressed an understanding of illness severity and/or terminality.

CONCLUSIONS

Inclusion of caregivers in discussions of goals of care, advance care planning, and palliative care and end-of-life services with patients and providers is imperative.