Continuity of Care During End of Life: An Evolutionary Concept Analysis

Barrier analysis for continuity of palliative care from health facility to household among adult cancer patients in Addis Ababa, Ethiopia

BACKGROUND

Annually 57 million people across the globe require palliative care, 76% are from low- and-middle income countries. Continuity of palliative care contributes to a decline in emergency room visits., decreased hospital deaths, improved patient satisfaction, better utilization of services, and cost savings. Despite efforts made to develop the palliative care guideline in Ethiopia, the service is not yet organized and linked to primary health care. This study aimed to explore barriers to the continuum of palliative care from facility to household for cancer patients in Addis Ababa.

METHODS

Qualitative exploratory study was conducted with face-to-face interviews with a total of 25 participants. The study population was adult cancer patients, primary caregivers, healthcare providers, volunteers, and nationwide advocates. Data were audio recorded, transcribed verbatim and finally imported to Open code version 4.02 software for coding and analysis. Thematic analysis was guided by Tanahashi's framework.

RESULTS

The key barriers to continuity of palliative care included opioid scarcity and turnover and shortage of healthcare workers. A shortfall of diagnostic materials, cost of medications, lack of government backing, and home-based center's enrollment capacity hampered accessibility. Care providers were instruments of cultural barriers in delivering appropriate end-of-life care, on the other hand, patients' preference for conventional medicine hindered acceptability. Lack of community volunteers, failure of health extension workers to link patients, and spatial limits fraught utilization. The lack of defined roles and services at several levels and the workload on healthcare professionals affected the effectiveness of the nexus.

CONCLUSION

The continuum of palliative care service from health facility to household in Ethiopia is yet in its infancy compromised by factors related to availability, accessibility, acceptability, utilization, and effectiveness. Further research is required to delineate the roles of various actors; the health sector should smudge out the continuum of palliation to cope with the growing need for palliative care.

Effectiveness of transitional care interventions in patients with serious illness and their caregivers: a systematic review protocol

OBJECTIVE

The objective of this review is to evaluate the effectiveness of transitional care interventions for seriously ill patients and their caregivers.

INTRODUCTION

Seriously ill patients and their caregivers may have complex health and social care needs that require services from numerous providers across multiple sectors. Transitional care interventions have been designed to enhance a collaborative approach among providers to facilitate the care transition process. However, the effectiveness of transitional care interventions for seriously ill patients and their caregivers, and the effects of such interventions on their outcomes, remain unclear.

INCLUSION CRITERIA

Randomized controlled trials with adult patients (≥18 years old) with serious illness and their caregivers involved in transitional care programs will be considered for inclusion. The patients' outcomes will include mortality and/or survival, symptoms (eg, pain, nausea), and health-related quality of life. The caregivers' outcomes will include caregiver burden, preparedness, and well-being.

METHODS

The JBI methodology for systematic reviews of effectiveness will be followed. The search strategy will aim to locate published and unpublished studies. Electronic databases, including PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, will be systematically searched from 2003 to the present. Studies in English, Italian, Spanish, French, and German will be included. Critical appraisal and data extraction will be conducted using standardized tools. Quantitative data will be pooled in statistical meta-analysis or, if statistical pooling is not possible, the findings will be reported narratively. Certainty of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022319848.

Conceptualizing the Value of Pediatric Concurrent Hospice Care

Given that pediatric concurrent hospice care has been available for more than a decade, it is appropriate to seek an understanding of the value of this care delivery approach. Value is the cost associated with achieving beneficial health outcomes. In pursuit of this goal, the current literature on pediatric concurrent hospice care was synthesized and used to develop a model to explain its value. Because of its relevance, the Value Assessment Framework was used to conceptualize the value of pediatric concurrent hospice care. This framework gauges the value of a health care service through 2 components: long-term effect and short-term affordability. The framework considers comparative clinical effectiveness, cost-effectiveness, other benefits or disadvantages, contextual considerations, and potential budget impact. Evidence from the literature suggested that the value of concurrent care depended on clinical outcomes evaluated, costs examined, medical services used, care coordinated, context considered, and budget impacted. The literature demonstrated that pediatric concurrent hospice care does offer significant value for children and their families. The conceptual model highlighted the need for a comprehensive approach to assessing value. The model is a useful framework for future research examining the value of concurrent hospice care.

Effectiveness of Pediatric Concurrent Hospice Care to Improve Continuity of Care

BACKGROUND

The 2010 Patient Protection and Affordable Care Act (ACA) mandated landmark hospice care legislation for children at end of life. Little is known about the impact of pediatric concurrent hospice care.

OBJECTIVE

The purpose of this study was to examine the effect of pediatric concurrent vs standard hospice care on end-of-life care continuity among Medicaid beneficiaries.

METHODS

Using national Medicaid data, we conducted a quasi-experimental designed study to estimate the effect of concurrent vs standard hospice care to improve end-of-life care continuity for children. Care continuity (i.e., hospice length of stay, hospice disenrollment, emergency room transition, and inpatient transition) was measured via claims data. Exposures were concurrent hospice vs standard hospice care. Using instrumental variable analysis, the effectiveness of exposures on care continuity was compared.

RESULTS

Concurrent hospice care affected care continuity. It resulted in longer lengths of stays in hospice (β = 2.76, P < .001) and reduced hospice live discharges (β = -2.80, P < .05), compared to standard hospice care. Concurrent care was not effective at reducing emergency room (β = 2.09, P < .001) or inpatient care (β = .007, P < .05) transitions during hospice enrollment.

CONCLUSION

Our study provides critical insight into the quality of care delivered for children at end of life. These findings have policy implications.

Continuity and coordination of care in highly selected chronic cancer patients treated with multiple repeat radiation therapy

Introduction and background

As cancer is developing into a chronic disease due to longer survival, continuity and coordination of oncological care are becoming more important for patients. As radiation oncology departments are an integral part of cancer care and as repeat irradiation becomes more commonplace, the relevance of continuity and coordination of care in operating procedures is increasing. This study aims to perform a single-institution analysis of cancer patients in which continuity and coordination of care matters most, namely the highly selected group with multiple repeat course radiotherapy throughout their chronic disease.

Materials and methods

All patients who received at least five courses of radiotherapy at the Department of Radiation Oncology at the University Hospital Zurich from 2011 to 2019 and who were alive at the time of the initiation of this project were included into this study. Patient and treatment characteristics were extracted from the hospital information and treatment planning systems. All patients completed two questionnaires on continuity of care, one of which was designed in-house and one of which was taken from the literature.

Results

Of the 33 patients identified at baseline, 20 (60.6%) participated in this study. A median of 6 years (range 3–13) elapsed between the first and the last visit at the cancer center. The median number of involved primary oncologists at the radiation oncology department was two (range 1–5). Fifty-seven percent of radiation therapy courses were preceded by a tumor board discussion. Both questionnaires showed high levels of experienced continuity of care. No statistically significant differences in experienced continuity of care between groups with more or less than two primary oncologists was found.

Discussion and conclusion

Patients treated with multiple repeat radiation therapy at our department over the past decade experienced high levels of continuity of care, yet further efforts should be undertaken to coordinate care among oncological disciplines in large cancer centers through better and increased use of interdisciplinary tumor boards.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01949-5.

Transitions during end-of-life care from the perspective of informal caregivers - A concept analysis using Rodgers' (2000) evolutionary approach

PURPOSE

To produce a conceptual and operational definition of transition, in the context of end-of-life care, as experienced by informal caregivers.

METHODS AND SAMPLE

The authors used Rodgers' (2000) concept analysis framework to examine this concept.

FINDINGS

Common themes emerged using Rodgers' (2000) inductive approach confirming transition for informal caregivers at the end of life as a process comprising the presence of trigger(s)/event(s), awareness, instability and engagement/learning while maintaining normality. There was also duration to this process that was often unknown and unpredictable. This concept analysis provides useful insight into understanding the complex dynamics of transition during this period. The primary antecedent of this concept, prompting transition, is a diagnosis of non-curative disease for the patient. In some cases, a gradual realisation rather than a formal diagnosis that the illness has progressed to a non-curative stage, can also be an antecedent.

CONCLUSION

Transition during end-of-life-care for informal caregivers can be a highly emotional time for this vulnerable cohort. Effective transitioning can ensure a stability and quality end-of-life outcomes, such as a peaceful death, as the awareness and learning that it brings, prompts planning actions for terminal care. Through recognising the findings of this concept analysis, deeper insight may be gained to support the provision of care, by nurses, to informal caregivers, prompting them towards effective transitions that foster the best interest of the patient.

Inequity in palliative care service full utilisation among patients with advanced cancer: a retrospective Cohort study

Background: Advanced cancer patients often die in hospital after receiving needless, aggressive treatment. Although palliative care improves symptom management, barriers to accessing palliative care services affect its utilisation, and such disparities challenge the equitable provision of palliative care. This study aimed to identify which factors are associated with inequitable palliative care service utilisation among advanced cancer patients by applying the Andersen Behavioural Model of Health Services Use.Material and methods: This was a retrospective cohort study using administrative healthcare data. A total of 13,656 patients residing in the Lazio region of Italy, who died of an advanced cancer-related cause-either in hospital or in a specialised palliative care facility-during the period of 2012-2016 were included in the study. Potential predictors of specialised palliative service utilisation were explored by grouping the following factors: predisposing factors (i.e., individuals' characteristics), enabling factors (i.e., systemic/structural factors) and need factors (i.e., type/severity of illness).Results: The logistic hierarchical regression showed that older patients (odds ratio [OR] = 1.45; <0.0001) of Caucasian ethnicity (OR = 4.17; 0.02), with a solid tumour (OR = 1.87; <0.0001) and with a longer survival time (OR = 2.09; <0.0001) were more likely to be enrolled in a palliative care service. Patients who lived farther from a specialised palliative care facility (OR = 0.13; <0.0001) and in an urban area (OR = 0.58; <0.0001) were less likely to be enrolled.Conclusion: This study found that socio-demographic (age, ethnicity), clinical (type of tumour, survival time) and organisational (area of residence, distance from service) factors affect the utilisation of specialised palliative care services. The fact that service utilisation is not only a function of patients' needs but also of other aspects demonstrates the presence of inequity in access to palliative care among advanced cancer patients.

Discharge of older patients with chronic diseases: What nurses do and what they record. An observational study

AIMS AND OBJECTIVES

To describe which nursing activities are observed during the discharge of older patients with chronic diseases and to investigate the consistency between the nursing activities actually observed and those documented.

BACKGROUND

The discharge from hospital of older patients with chronic diseases is a critical transition that can lead to dissatisfaction, delays in discharge, re-admission, adverse events and increased mortality. Although nurses' interventions during discharge are important for patient outcomes, little is known about the nursing activities actually performed as compared with those documented.

DESIGN

An observational study of the nursing activities performed during patients' discharge and a retrospective audit of the nursing records of the same patients and nurses.

METHODS

Structured nonparticipant observations were conducted of the activities performed by nurses at discharge. A retrospective audit of the nursing records relating to patient discharge, including the nursing diary and the assessment of critical issues at hospital discharge, was also conducted. The STROBE guidelines were followed (See Supporting Information Appendix S2).

RESULTS

During hospital discharge of 102 patients, 1,224 nursing activities were observed. The number of activities was not related to patients' age, gender and educational level, nor to nurses' postgraduate education. Statistically significant correlations emerged between the number of activities observed and the nurses' work experience.

CONCLUSIONS

A predefined discharge plan guiding nurses' activities during discharge would enable them to respond better to the care needs of elderly patients.

RELEVANCE TO CLINICAL PRACTICE

Results from the study could help clinical nurses to address care priorities of patients at discharge, by using appropriate plans and checklists and improving recording rates. Novice nurses should be supported when caring for elderly patients with chronic disease at discharge.

Validity and reliability of the Palliative Care Transition Measure for Caregivers (PCTM-C)

OBJECTIVE

Patients suffering from advanced disease face different care transitions. The transition from acute to palliative care is challenging and may lead to the discontinuity of care. Family caregivers become important sources of information, as patients begin to experience difficulties in coping with emotional transition events. The Care Transition Measure was developed to evaluate care transitions as experienced by the elderly. It has never been used in palliative care. The aim of this study was to test the validity and reliability of a modified version of the Palliative Care Transition Measure, specifically the Palliative Care Transition Measure for Caregivers (PCTM-C).

METHOD

The study included two main phases. Phase I focused on the construction of a modified version of the Palliative Care Transition Measure through two focus groups and by computing the content validity index. Phase II focused on testing the psychometric properties of the PCTM-C on 272 family caregivers through confirmatory factor analysis.

RESULT

The content validity index for each of the items was higher than 0.80, whereas that for the scale was 0.95. The model tested with confirmatory factor analysis fitted the data well and confirmed that the transition measures referred to communication, integrated care and a trusting-relationship, and therefore the core dimensions of continuity according to existing conceptual models. The internal consistency was high (Cronbach's alpha = 0.94).

SIGNIFICANCE OF RESULTS

The PCTM-C proved to be a suitable measure of the quality of such transitions. It may be used in clinical practice as a continuity quality indicator and has the potential to guide interventions to enhance family caregivers' experience of care continuity.

How continuity of care is experienced within the context of integrated palliative care: A qualitative study with patients and family caregivers in five European countries

BACKGROUND

Patients with advanced diseases often experience deficient continuity of care. Although integrated palliative care promotes continuity of care, it is not clear how it can be optimized to improve continuity of care experiences.

AIM

To examine how relational, informational and management continuity of care are experienced by patients with advanced diseases and their family caregivers receiving care from several integrated palliative care initiatives in five European countries.

DESIGN

We adopted a longitudinal qualitative study design including two interviews (interval 3 months) with patients and family caregivers focusing on how health care professionals responded to their needs. Interviews were audio-recorded and transcribed verbatim. Analysis involved a two-step qualitative content approach.

SETTING/PARTICIPANTS

A total of 22 integrated palliative care initiatives (established local palliative care collaborations) were selected in Belgium, Germany, Hungary, the Netherlands and the United Kingdom. We recruited 152 patients (63% cancer, 24% chronic obstructive pulmonary disease, 13% heart failure; life expectancy <1 year; mean age 68 years, 56% female) and 92 family caregivers (mean age 61 years, 66% female).

RESULTS

Trusted relationships with a small number of key health care professionals to receive tailored care and easily access help were essential. Relational continuity was often deficient, especially with general practitioners. Although informational and management continuity was often lacking in care provision, collaborative integrated palliative care initiatives were related to consistent and coherent care.

CONCLUSION

Patients and family caregivers most likely experience continuity of care by having a small number of trusted health care professionals who are available, provide multidisciplinary care and regularly transfer information to all health care professionals involved. Optimizing continuity of care requires further integration of integrated palliative care initiatives with other health care professionals involved in the patients' care networks.

Construction and validation of nursing diagnoses for people in palliative care

Objective:

to construct and validate nursing diagnoses for people in palliative care based on the Dignity-Conserving Care Model and the International Classification for Nursing Practice.

Method:

a two-stage methodological study: 1) construction of the database of clinically and culturally relevant terms for the nursing care for people in palliative care and 2) construction of nursing diagnoses from the database of terms, based on the guidelines of the International Council of Nurses.

Results:

the 262 terms validated constituted a database of terms from which 56 nursing diagnoses were developed. Of these, 33 were validated by a group of 26 experts, and classified in the three categories of the Dignity-Conserving Care Model: illness-related concerns (21); dignity-conserving repertoire (9); and social dignity inventory (3).

Conclusion:

of the 33 validated diagnoses, 18 of them could be included in the update of the Catalog of the International Classification for Nursing Practice - palliative care for a dignified death. The study contributes to support the clinical reasoning and decision making of the nurse.

Experiences of security and continuity of care: Patients' and families' narratives about the work of specialized palliative home care teams

BACKGROUND

Those who are seriously ill and facing death are often living with physical, emotional, social, and spiritual suffering. Teamwork is considered to be necessary to holistically meet the diverse needs of patients in palliative care. Reviews of studies regarding palliative care team outcomes have concluded that teams provide benefits, especially regarding pain and symptom management. Much of the research concerning palliative care teams has been performed from the perspective of the service providers and has less often focused on patients' and families' experiences of care.

OBJECTIVE

Our aim was to investigate how the team's work is manifested in care episodes narrated by patients and families in specialized palliative home care (SPHC).

METHOD

A total of 13 interviews were conducted with patients and families receiving specialized home care. Six patients and seven family members were recruited through SPHC team leaders. Interviews were transcribed verbatim and the transcripts qualitatively analyzed into themes.

RESULTS

Two themes were constructed through thematic analysis: (1) security ("They are always available," "I get the help I need quickly"); and (2) continuity of care ("They know me/us, our whole situation and they really care"). Of the 74 care episodes, 50 were descriptions of regularly scheduled visits, while 24 related to acute care visits and/or interventions.

SIGNIFICANCE OF RESULTS

Patients' and family members' descriptions of the work of SPHC teams are conceptualized through experiences of security and continuity of care. Experiences of security are fostered through the 24/7 availability of the team, sensitivity and flexibility in meeting patients' and families' needs, and practical adjustments to enable care at home. Experiences of continuity of care are fostered through the team's collective approach, where the individual team member knows the patients and family members, including their whole situation, and cares about the little things in life as well as caring for the family unit.