The experience of living with advanced-stage cancer: a thematic synthesis of the literature

"The Most Fantastic Thing is Coming Here as an Individual and Going to Bed as Part of a Group": Participants' Experiences From a Residential Course, for People With Advanced Cancer

People who suffer from advanced cancer may experience a loss of ability to participate in everyday life and meaningful activities, challenging their sense of identity and social relations. Social support in patient-to-patient interactions and the sharing of experiences with people in similar situations may help alleviate distress. This article is based on an ethnographic field study carried out in relation to three residential narrative courses, which included 36 persons with advanced cancer. In this study, we aimed to explore whether the courses were perceived as significant by the participants and, if so, in what ways. The field work included 185 hr of observations, six focus group interviews and nine individual interviews. The data were analyzed using an abductive thematic approach. Our findings indicate that the residential courses were generally experienced as meaningful and that in particular the setting, the community, and gaining hope were experienced as significant.

Psychodynamic psychotherapy in serious physical illness: A systematic literature review of approaches and techniques for the treatment of existential distress and mental disorders

Individuals with life-limiting physical illness experience lower mental health due to existential distress (e.g., demoralization, death anxiety) and mental disorders (e.g., depression, anxiety). Psychodynamic psychotherapy may be helpful in alleviating such distress by focusing patients' unconscious emotional and relational motivations. There is yet limited knowledge on the application of psychodynamic psychotherapies in this population. We systematically searched electronic databases and analyzed results using meta-ethnography. Of 15,112 identified records, we included 31 qualitative studies applying psychodynamic psychotherapies (n = 69, mean age: 49.3 [SD = 16.9)], 56% female). Psychodynamic treatment in this population can be beneficial when considering modification of the treatment setting to the illness reality, balancing needs for autonomy and separation in light of helplessness and death anxiety, and careful integration of supportive interventions and conflict-oriented interventions (e.g., exploring relational issues that interfere with mourning illness-related loss). We discuss future directions for the development and evaluation of treatments specific to serious physical illness.

What patients with advanced cancer experience as helpful in navigating their life with a long-term response: a qualitative study

PURPOSE

Despite improved survival for people with advanced cancer due to new medical treatments, a growing group of long-term responders (LTRs) has to learn to live with uncertainties that affect several life domains. At the core of their experience, they neither feel like a patient nor feel healthy. Despite growing awareness of LTRs' experiences, learning more about how they cope with their long-term response can provide insight into how to best support them. Our study aimed to gain a deeper understanding what LTRs experience as helpful in navigating life with a long-term response.

METHODS

We conducted an exploratory qualitative study using thematic data analysis. Semi-structured in-depth interviews were conducted with 17 participants with advanced melanoma or lung cancer with confirmed response or long-term stable disease while on immuno- or targeted therapy.

RESULTS

LTRs reported several strategies to navigate life with a long-term response, for example, by involving the social environment, seeing uncertainty as an opportunity, and being present in the moment. This helped them to reclaim a sense of control, alter their perspective, and reshape their lives according to their values.

CONCLUSION

Using different coping strategies enables LTRs to acknowledge both their sick and healthy side. Striking a healthy balance between being oriented on feeling sick or feeling healthy can help LTRs and their close others to navigate life with a long-term response. Healthcare professionals can provide support by recognizing whether LTRs are oriented at feeling sick or healthy, and by actively involving close others during medical appointments.

The Hematology Cancer Patient Experience of "Facing Death" in the Last Year of Life: A Constructivist Grounded Theory Study

BACKGROUND

For hematology cancer patients, the process of dying is described as "troublesome." Qualitative studies have focused on views of healthcare professionals and caregiver stakeholders. To date, there have been no studies from the patient's perspective on facing death while in the last year of life.

OBJECTIVE

The aim of this study was to develop an understanding of the hematology cancer patient's experience of the process of dying in the last year of life.

METHODS

The study method was constructivist grounded theory using semistructured interviews, a constant comparison technique, and memoing to collection and analysis of data. The 21 participants were attending a UK cancer center, a cancer unit, or a hospice.

RESULTS

This article describes 1 core category within the incurable hematology cancer illness trajectory through 4 subcategories: transitional phase, chronic phase, dying phase, and liminal phase.

CONCLUSION

This unique study illustrates that, although life can be prolonged, "facing death" still occurs upon hospitalization and relapse regularly over the illness trajectory.

IMPLICATIONS FOR PRACTICE

It is important that clinical practice acknowledges those participants in an incurable illness trajectory while living are focused on avoiding death rather than the ability to cure the disease. Services need to be responsive to the ambiguity of both living and dying by providing holistic management simultaneously, especially after critical episodes of care, to enhance the process of care in the last year of life, and assessment should incorporate the discussion of experiencing life-threatening events.

The state of transience, and its influence on the wish to die of advanced disease patients: insights from a qualitative phenomenological study

BACKGROUND

The experience of Wish to Die is common in patients living with Advanced Disease. It has been studied worldwide and qualitative studies have contributed to the understanding of the complexity of the phenomenon of the WTD but a deeper understanding on the individual's views is still needed. The objective of this study was to identify common characteristics of the experience of wish to die in advanced disease.

METHODS

A phenomenological study was carried out with multicenter participation of patients with advanced disease who had expressed their wish to die to health professionals. Semi-structured interviews were employed to obtain an in-depth perspective of each patient's lived experience. A phenomenological analysis of the data collected was performed to describe and explore the characteristic aspects of the phenomenon under study.

RESULTS

Fourteen patients with advanced disease were interviewed. Most of them had cancer. In the analysis of the patients' accounts of their experiences, three common characteristics were identified: a) experiencing a state of transience; b) the attempt to reconnect with oneself; and c) additional disease-related aspects that influence the wish to die. Patients expressed the need for a safe space to address the wish to die and the importance of receiving care that considers both 'being' and 'doing'.

CONCLUSIONS

Patients with advanced disease and wish to die experience a state of transience where the patient lives and ephemeral state of existence. Interventions focused on reinforcing the intrinsic value of the individual emerge as essential components of a compassionate accompaniment of those facing the wish to die.

Occupational adaptation for adults living with advanced cancer: A phenomenological longitudinal study

INTRODUCTION

People living with advanced cancer want to continue participating in their valued occupations amid cancer progression. However, increasing dependence and bodily deterioration challenge a person's ability to do so, thus requiring adaptation to how they engage in their occupations. Theoretical frameworks on the process of occupational adaptation often do not address the implications of progressive functional decline.

METHODS

A longitudinal phenomenological design was used to understand the lived experience of occupational engagement for working-aged adults living with advanced cancer. A semi-structured interview series explored participants' experience of occupational engagement and how this changed over time. Data were analysed thematically and mapped against the Model of Human Occupation (MOHO).

FINDINGS

Eight adults (40-64 years old) participated in 33 interviews over 19 months. Three themes were constructed from the data: ongoing adaptation through doing, the significance of volition in adaptation, and everyday life is contingent on my environment. Study findings demonstrate that the process of adaptation occurs through occupational engagement, is motivated by volition, and is affected by the environment. Volition and the environment play a more central role in occupational adaptation than occupational competency for the advanced cancer cohort.

CONCLUSION

Study findings further MOHO's theoretical conceptualisation of occupational adaptation by identifying the centrality of volition and the environment in the process of adaptation. For people living with advanced cancer, disease progression results in unremitting functional decline, thus rendering competency an unstable and untenable construct. Rather, this paper argues that occupational adaptation is facilitated by volition (i.e., the motivation behind the doing) and the environment, thus fostering a sense of identity and meaning at the end of life. Occupational therapists' awareness of the significance of volition and the environment can thus foster continued occupational engagement and meaning at the end of life for people living with advanced cancer.

Experience of patients considering or using checkpoint inhibitors in cancer treatment: a systematic review of qualitative research

Increasing numbers of patients with cancer are considering or undergoing immunotherapy, however, little is known about patients' perspectives on this treatment. We undertook a systematic review for use by clinicians and researchers, consolidating published qualitative research studies on patient experience of checkpoint inhibitor therapy. A search of Medline, Embase, and PsycINFO was carried out for publications in English to 30 June 2022. Publications were selected if they reported a qualitative study of patient experience with checkpoint inhibitor therapy for cancer, either by patients or their families or carers. Quality was appraised using the Johanna Briggs Institute quality assessment tool for qualitative studies. A thematic synthesis was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard was followed. We identified 17 eligible studies published between 2017 and 2022, 9 using mixed methods, and 8 solely using qualitative methods. Most studies reported on the experiences of patients with advanced stage melanoma and were using the earliest approved checkpoint inhibitors for cancer therapy. Studies met most formal quality criteria but varied in the extent of their qualitative explorations of data; some mixed methods studies had limited reporting of qualitative results. Through thematic synthesis, we categorized study findings into four domains: (1) treatment decision-making; (2) success with immunotherapy; (3) treatment-related adverse events (AEs); and (4) quality of life on immunotherapy. Our review identified several areas with potential for improving the care system. These include, for example: routinely linking patients to peers who have experienced this therapy; improving the capacity of patients and carers to identify and report AEs faster; and supporting patients and carers to live with changed circumstances after successful treatment. Most studies focused on patients who had successful treatment, effectively excluding those who do not respond or who discontinue due to serious side effects; future research targets are suggested.

Advanced Cancer in Young Adults (YAs): Living in a Liminal Space

Young adults (YAs), defined as individuals between the ages of 18 and 39 years, experience unique challenges when diagnosed with advanced cancer. Using the social constructivist grounded theory approach, we aimed to develop a theoretical understanding of how YAs live day to day with their diagnosis. A sample of 25 YAs (aged 22-39 years) with advanced cancer from across Canada participated in semi-structured interviews. Findings illustrate that the YAs described day-to-day life as an oscillating experience swinging between two opposing disease outcomes: (1) hoping for a cure and (2) facing the possibility of premature death. Oscillating between these potential outcomes was characterized as living in a liminal space wherein participants were unsure how to live from one day to the next. The participants oscillated at various rates, with different factors influencing the rate of oscillation, including inconsistent and poor messaging from their oncologists or treatment team, progression or regression of their cancer, and changes in their physical functioning and mental health. These findings provide a theoretical framework for designing interventions to help YAs adapt to their circumstance.

A qualitative study on the healthcare experiences of adolescents and young adults (AYA) with an uncertain or poor cancer prognosis

PURPOSE

Treatment advancements have improved life expectancy for adolescents and young adults (AYAs) with an uncertain and/or poor cancer prognosis (UPCP) and change clinical practice. This improved survival requires a different approach and specific expertise to meet the needs of this group. The aim of this study is to explore the health care experiences of AYAs with a UPCP.

METHODS

We conducted a multicenter qualitative study using semi-structured interviews and elements of the grounded theory by Corbin and Strauss.

RESULTS

Interviews were conducted with 46 AYAs with a UPCP. They were on average 33.4 years old (age range 23-44), and most of them were woman (63%). Additionally, five AYAs with a UPCP participated as AYA research partners in two focus groups. They were on average 31.8 years old and four of them were woman. AYAs with a UPCP reported four pillars for a satisfied healthcare experience: (1) trust, (2) tailored communication, (3) holistic empathic open attitude, and (4) care being offered (pro-)actively. They reported both optimal and suboptimal experiences about distrust based on a delay in diagnostic trajectory, lack of tailored communication and discussion of sensitive topics, preference for a holistic approach, and struggles with finding the way to get additional healthcare support.

CONCLUSION

For AYAs with a UPCP, it is important that both age-specific issues and issues related to the UPCP are understood and addressed; however, this seems not yet optimally implemented in clinical practice. This emphasizes the importance of providing this patient group with tailored care incorporating both aspects. Healthcare professionals need to be supported with training and tools to understand the healthcare needs of AYAs with a UPCP. AYAs can be empowered to take more control over their own healthcare needs.

Psychosocial functioning in individuals with advanced oesophago-gastric cancer: a mixed methods systematic review

BACKGROUND

Oesophago-gastric cancer is an aggressive disease with a high rate of recurrence and mortality across the disease trajectory. Reduced psychosocial functioning has been evidenced amongst those with advanced disease, however little is known about the contributing factors. Determining these factors is an important clinical consideration to inform assessment and intervention. This review aimed to synthesise the available evidence on the psychosocial functioning of individuals with advanced oesophago-gastric cancer and their carers.

METHODS

A JBI mixed-methods systematic review. Four bibliographic databases, MEDLINE, Embase, PsycINFO, and CINAHL, were searched. Quantitative and qualitative studies were screened for inclusion and critically appraised for methodological quality. Both types of data were extracted using JBI tools for mixed-methods systematic reviews. A convergent segregated approach to synthesis and integration was used. The findings of the synthesis have been configured according to JBI methodology.

RESULTS

A total of 12 studies were included in this review, including 6 quantitative studies and 6 qualitative studies. The quantitative results provide preliminary indication of several physical, biological, psychological and macro-level contextual factors associated with psychosocial functioning in this clinical population. The qualitative findings shed light on a range of physical, psychosocial, and existential challenges faced by advanced oesophago-gastric cancer patients. These multiple and often persistent challenges appear to cause considerable distress; however, patients describe the importance of maintaining a sense of normality and control over their illness and its effects. Patients value continuity and structure, however many report shortcomings when accessing care. No findings reporting the experiences from the perspective of carers were found, therefore all findings represent the perspective of the patient.

CONCLUSIONS

Further high-quality research is needed to understand how best to support and manage the palliative care needs of individuals living with advanced oesophago-gastric cancer. Implications for practice are discussed, suggesting that psychosocial interventions, complex symptom management and continuity of care could improve the psychosocial functioning of individuals in this setting.

PRE-REGISTRATION

The systematic review was pre-registered at the International Prospective Register of Systematic Reviews (PROSPERO; CRD42020181273) and the protocol can be viewed on the OSF ( http://osf.io/exuzf ).

"I won't get to live my life the way I planned it": A qualitative analysis of the experiences of adolescents and young adults with advanced cancer

BACKGROUND

Individuals with advanced cancer face complex challenges, including prognostic uncertainty and evolving goals of care. Despite the unique psychosocial support needs of adolescents and young adults (AYAs), few studies have specifically examined AYA perspectives of and experiences with advanced cancer. The objective of this study was to describe the experience, needs, and perspectives of pediatric AYAs with advanced cancer.

PROCEDURE

We invited English-speaking AYAs (age 14-25 years) who were receiving treatment for advanced cancer at our single tertiary pediatric cancer center to participate in semi-structured interviews. We used directed content analysis for codebook development and then applied in-depth thematic network analysis to describe their perspectives and experiences with advanced cancer.

RESULTS

A total of 32 AYAs (86% of approached) completed interviews. A slight majority were male (59%) and non-Hispanic White (56%). Most were diagnosed with leukemia/lymphoma, had recurrent disease (84%), and were a mean 53 months from initial diagnosis. Organizing themes of "not being able to beat this," "not wanting to miss out," and "living each day" generated the global theme "do I have a future?" "Making tough medical decisions," "adjusting life/plans/perspectives," and "decisions about dying" were organized into the global theme "those decisions … were really hard." "Feeling like there is no one to talk to," "being away from family and friends," and "feeling like a burden" generated the global theme "I felt very alone."

CONCLUSIONS

Pediatric AYAs with advanced cancer describe unique challenges. Psychological support interventions are needed to empower AYAs to navigate difficult decisions and to cope with isolation.

The perception of life and death in patients with end-of-life stage cancer: A systematic review of qualitative research

PURPOSE

This study aims to clarify the perceptions on life and death among patients with the end-of-life stage cancer through a systematic review.

METHODS

The search strategy combined MeSH terminology with free text searches, and was applied to the PubMed, CINAHL, Embase, and ICHUSHI (Japan Medical Abstracts Society) databases covering from 2010 to 5/2022. To ensure the quality of the research included, the Critical Appraisal Skills Program Qualitative Studies Checklist was used. Data relating to the perceptions of life and death of patients with the end-of-life stage cancer was extracted and analyzed with reference to qualitative meta-synthesis methods.

RESULTS

Ultimately, 50 studies were included. Five themes were derived based on the perceptions of life and death of patients with the end-of-life stage cancer: despair, making sense of death, how to live the rest of life, special feelings for loved ones, and fluctuation. By making sense of death in their own way, and reconciling it with their current situation, patients with the end-of-life stage cancer, even in despair over their impending death, look ahead into the future and their surroundings and consider how they would live the remaining time they have. During this time, the special feelings they have for their loved ones make an impact.

CONCLUSIONS

An important new finding from this study lies in the fact that the patients' desire to live as ordinary people who were not patients were expressed as a face that they hid from their families. Further research is needed in low-income countries/regions.

The intentional pursuit of everyday life while dying: A longitudinal qualitative study of working-aged adults living with advanced cancer

BACKGROUND

People living with advanced cancer experience functional decline and increasing difficulty participating in activities of daily living over their final year of life, consequently reducing quality of life. Palliative rehabilitation may serve to mitigate some of these challenges by optimising function. However, limited research and theory explore the rehabilitative process of adaptation amid increasing dependency, often experienced by people living with advanced cancer.

AIM

To explore the lived experience of everyday life for working-aged adults living with advanced cancer, and how this changes over time.

DESIGN

A longitudinal hermeneutic phenomenological approach was employed, using in-depth semi-structured interviews. Data was analysed using inductive thematic analysis, and findings mapped against the Model of Human Occupation and illness experience literature.

SETTING/PARTICIPANTS

Purposively sampled working-aged adults (40-64 years) with advanced cancer were recruited by a rural home care team in Western Canada.

RESULTS

Thirty-three in-depth interviews were conducted over 19 months with eight adults living with advanced cancer. Advanced cancer and other losses have a disruptive impact on daily life. Despite experiencing progressive functional decline, these adults intentionally sought to participate in valued everyday activities. Adaptation to ongoing deterioration occurred through engagement in daily life.

CONCLUSIONS

Despite experiencing disruption to routines and daily life, people living with advanced cancer seek to continue doing what is important to them, albeit in a modified form. Adaptation to functional decline is an active, ongoing process and occurs through continued engagement in activities. Palliative rehabilitation can facilitate participation in everyday life.

Unmet care needs of patients with advanced cancer and their relatives: multicentre observational study

OBJECTIVES

The care needs of patients with advanced cancer and their relatives change throughout the disease trajectory. This study focused on the care-related problems and needs of patients with advanced cancer and their relatives. This was done from the perspective of centres for information and support.

METHODS

This cross-sectional study used data from the eQuiPe study: an observational cohort study in which 40 Dutch hospitals participated. All adult patients with a diagnosis of a metastasised tumour and their relatives were eligible. Measures included information on the patients' and relatives' care problems and needs, assessed by the short version of the Problems and Needs in Palliative Care questionnaire. Socioeconomic demographics were also collected.

RESULTS

1103 patients with advanced cancer and 831 relatives were included. Both patients (M=60.3, SD=29.0) and relatives (M=59.2, SD=26.6) experienced most problems in the domain of 'psychological issues'. Both patients (M=14.0, SD=24.2) and relatives (M=17.7, SD=25.7) most frequently reported unmet needs within this domain. The most often reported unmet need by patients was 'worrying about the future of my loved ones' (22.0%); for relatives this was 'fear for physical suffering of the patient' (32.8%). There was no clear relationship between socioeconomic demographics and the experienced unmet needs.

CONCLUSIONS

The most often mentioned unmet needs consisted of fears and worries, followed by a broad range of topics within multiple domains. Centres for information and support may play a role in reducing the unmet needs of (potential) visitors as these centres provide support on a broad range of topics.

Perceptions of an educational intervention for family caregivers of palliative care patients

BACKGROUND

Nursing interventions aimed at family caregivers of palliative cancer patients require not only an objective evaluation, but also subjective consideration of their contributions, and a qualitative evaluation that provides an in-depth understanding of these interventions.

AIMS

This study aimed to explore the perceptions that family caregivers of palliative cancer patients had of the nursing intervention, PalliActive Caregivers, in reducing the uncertainty associated with illness and improving the caregiver's quality of life.

METHODS

A qualitative approach with content analysis was used. Telephone interviews were conducted with 23 caregivers who participated in the intervention.

FINDINGS

Five themes emerged from the content analysis: consolidating physical care, adopting a positive attitude, strengthening the support available to the caregiver, strengthening spirituality and strengthening relationships.

CONCLUSION

The themes showed a positive impact of the intervention on aspects such as the caregiver's ability to cope, spirituality and social support of caregivers. The results also indicated the possibility of conducting this type of study to identify other assessment variables for future interventions.

The process of reaching psychological adjustment among adult women diagnosed with metastatic breast cancer and receiving cancer pharmacotherapy

Objective

This study clarified the process by which adult women diagnosed with metastatic breast cancer (MBC) and undergoing cancer pharmacotherapy reach psychological adjustment.

Methods

A semistructured interview was conducted with adult women who had received their MBC diagnosis. The data collected were analyzed using Kinoshita's modified grounded theory approach.

Results

A total of 21 women with an average age of 50 years participated in the study. Seven categories and 21 concepts were generated through the analysis. Upon being diagnosed with MBC by a doctor, the participants felt the "threat of death" and "conflict with painful cancer pharmacotherapy." Thereafter, they received "encouragement from strong supporters," consolidated their "resolve to save their life," and began cancer pharmacotherapy. During the therapy, they made "efforts to internalize MBC" to overcome the distress arising from the "struggle to internalize MBC," and this led to the "expansion of self-awareness."

Conclusions

Despite finding themselves in harsh circumstances, the participants remained focused on the big picture and realized that cancer had changed their values and outlook on life, leading to psychological growth. It is important for nurses to provide systematic and continuous support from the time of MBC diagnosis.

"Double awareness"-adolescents and young adults coping with an uncertain or poor cancer prognosis: A qualitative study

Introduction

Adolescents and young adults with an uncertain or poor cancer prognosis (UPCP) are confronted with ongoing and unique age-specific challenges, which forms an enormous burden. To date, little is known about the way AYAs living with a UPCP cope with their situation. Therefore, this study explores how AYAs with a UPCP cope with the daily challenges of their disease.

Method

We conducted semi-structured in-depth interviews among AYAs with a UPCP. Patients of the three AYA subgroups were interviewed (traditional survivors, new survivors, low-grade glioma survivors), since we expected different coping strategies among these subgroups. Interviews were analyzed using elements of the Grounded Theory by Corbin and Strauss. AYA patients were actively involved as research partners.

Results

In total 46 AYAs with UPCP participated, they were on average 33.4 years old (age range 23-44) and most of them were woman (63%). Most common tumor types were low-grade gliomas (16), sarcomas (7), breast cancers (6) and lung cancers (6). We identified seven coping strategies in order to reduce the suffering from the experienced challenges: (1) minimizing impact of cancer, (2) taking and seeking control, (3) coming to terms, (4) being positive, (5) seeking and receiving support, (6) carpe diem and (7) being consciously alive.

Conclusion

This study found seven coping strategies around the concept of 'double awareness' and showcases that AYAs are able to actively cope with their disease but prefer to actively choose life over illness. The findings call for CALM therapy and informal AYA support meetings to support this group to cope well with their disease.

"Finding my way in a maze while the clock is ticking": The daily life challenges of adolescents and young adults with an uncertain or poor cancer prognosis

INTRODUCTION

Increasingly more adolescent and young adult (AYA, aged 18-39 years) patients with an uncertain and/or poor cancer prognosis (UPCP) are gaining life-years because of novel treatments or refinement of established therapies, and sometimes even face the prospect of long-term disease control. This study aims to examine the challenges of AYAs with a UPCP in daily life to inform the development of AYA care programs.

METHODS

Semi-structured in-depth interviews were conducted among AYAs with a UPCP. Since we expected differences in experiences between three AYA subgroups, we interviewed patients of these subgroups (1): traditional survivors (2), low-grade glioma survivors, and (3) new survivors. Interviews were analyzed using elements of grounded theory. AYA patients were actively involved as research partners.

RESULTS

In total 46 AYAs with UPCP participated and shared their challenges in daily life. They were on average 33.4 years old (age range 23-44) and most of them were women (63%). The most common tumor types were low-grade gliomas (16), sarcomas (7), breast cancers (6), and lung cancers (6). We identified five primary themes: (1) feeling inferior to previous self and others (e.g. feeling useless, who wants me in a relationship), (2) feeling of being alone (e.g. lonely thoughts, nobody really gets me), (3) ongoing confrontation (e.g. it is always there, own decline), (4) grief about life (e.g. grief about life I did not get, grief about old life), and (5) loss of control over the future (e.g. not able to make future plans, waiting for growth). Although all of the challenges were identified in the three AYA subgroups, the perceived intensity of the challenges differed slightly between the subgroups.

DISCUSSION

AYAs living with a UPCP experience challenges associated to their sense of altered identity, their position in the social network, and the future uncertainties. This study highlights the importance to recognize and acknowledge the unique challenges of this group. To provide age-specific care, it is important to embed acceptance and commitment therapy and AYA peer support within the healthcare system and other care programs to support AYAs to live well with their disease.

Passing through end-of-life suffering: Possible or not? Results from a qualitative inquiry

The objective of this study was to understand the factors associated with "passing through suffering" in terminal illness. We interviewed 19 adults diagnosed with terminal disease in palliative stage. Interviews were analyzed using thematic analysis. Four axes of understanding were generated. In the first, participants discussed the will to "feel alive" despite the disease. The second, the process of acceptance, is based on lucidity and on letting go. The third highlights the importance of relationships with others. The fourth axis describes the consequences of this passage through suffering. This study highlights a phenomenon of adapting to suffering.

"Who can I ring? Where can I go?" Living with advanced cancer whilst navigating the health system: a qualitative study

BACKGROUND

People with advanced cancer often experience greater physical and psychosocial morbidity compared to those with early disease. Limited research has focused on their experiences within the Australian health system. The aim of this study was to explore the lived experiences of adults receiving care for advanced cancer.

METHODS

A qualitative design with a descriptive phenomenological approach was used to explore the lived experiences of people with advanced cancer following their diagnosis. Twenty-three people living with an advanced solid malignancy receiving care were referred by their oncologists to take part in an interview conducted at their home, the hospital, or over the phone.

RESULTS

Three key themes emerged relating to participants' experiences of living with advanced cancer: (1) living with a life-limiting diagnosis and uncertainty, (2) living with symptom burden and side effects, and (3) living within the health system, with two subthemes, the patient-clinician relationship, and care coordination. Participant relationships with their health professionals were particularly important and had a defining impact on whether patient experiences living with cancer were positive or negative.

CONCLUSION

People with advanced cancer experienced broad variation in their experiences navigating the health system, and their relationships with clinicians and other health professionals were important factors affecting their perceptions of their experiences. Attention to the coordination of care for people with advanced cancer is necessary to improve their experiences and improve symptom control and the management of their psychosocial burden.

Women's lived experiences of advanced cervical cancer: a descriptive qualitative study

AIM

To explore the lived experiences of women with advanced incurable cervical cancer attending a palliative care service in Uganda.

METHODS

This qualitative and exploratory study was conducted at Mobile Hospice Mbarara in South Western Uganda. The target population was a convenience sample of all patients with a confirmed histological diagnosis of advanced cervical cancer; stage 2B to 4B, and clinically advanced disease. Demographic data were collected prior to conducting semi-structured audio-taped interviews. Transcripts were read and re-read, coded and codes were then abstracted into emergent broad-based meaningful themes by consensus.

RESULTS

A total of 10 participants, average age of 53.4, age range 40-71, cancer staging 2B to 4 and average duration of illness 3.5 years were interviewed. Six themes emerged from the data: socio-demographic profiles of the women; road to cancer diagnosis; effects of disease on women's quality of life; experiences with main stream medicine; adapting to having cancer and needs of the women.

CONCLUSIONS

Living with advanced incurable cervical cancer is associated with significant disruptions in all domains of life. Good palliative care enables patients to achieve an optimal quality life. Poverty and a lack of knowledge about cervical cancer among women and health workers are the strongest predictors of a patient receiving a late advanced diagnosis.

The incurable metastatic breast cancer experience through metaphors: the fight and the unveiling

Purpose: War metaphors are omnipresent in public and medical discourse on cancer . If some studies suggest that cancer patients may view their experiences as afight, few studies focus on the metaphors that patients create from their subjective experiences. The aim was to better understand the experience of four women with incurabale metastatic breast cancer from the metaphors they used in personal cancer blogs.Methods: An interpretive phenomenological analysis (IPA) was used to analyze these women's experience and metaphors of cancer.Results: Two metaphors carried the meaning of metastatic breast cancer experience: the fight and the unveiling. The results show that the war metaphor had a unique meaning for the bloggers who lived with incurable breast cancer: they revealed the difficulty of fighting cancer and eventually collapsing in battle, although a renewed look at life had developed in parallel to their struggle. The bloggers thus tried to lift the veil on this complex experience.Conclusion: The results highlight the need for women with metastatic breast cancer to be able to tell and share their experience in a supportive context and to reinvest the war metaphor in order to express themselves in a more authentic way.

Psychological well-being in palliative care: A systematic review

OBJECTIVE

To review which are the most influential variables in achieving levels of psychological well-being at the end of life and to verify whether, as certain studies suggest, spirituality, resilience and social support are the pillars on which the psychological well-being construct is based.

METHOD

A systematic search through the Scopus, Pubmed and PsycInfo electronic databases was carried out using keywords such as: "wellbeing" OR "psychological-well-being" AND "resilience" AND "spirituality" AND "social support" AND "palliative care" and their multiple combinations.

RESULTS

Eleven studies were selected, in which terms such as spiritual well-being, absence of discomfort and quality of life were used in substitution of psychological well-being and a certain consensus was found regarding whether resilience, spirituality and social support are predictive variables of psychological well-being.

CONCLUSIONS

Resilience, social support and spirituality are highly relevant variables at the end of life and contribute decisively towards psychological well-being.

Palliative Integration Into Ambulatory Oncology: An Advance Care Planning Quality Improvement Project

Advance care planning (ACP) is essential to ensuring that patient-centered end-of-life goals are respected if a health crisis occurs. Advanced practitioner barriers to ACP include insufficient time and limited confidence in discussions. The purpose of this quality improvement project was to increase advanced cancer patients' electronic health record (EHR) documented surrogate decision maker and ACP documentation by 25% over 8 weeks. A secondary aim was to decrease patients' decisional conflict scores (DCS) related to life-sustaining treatment preferences after a clinical nurse specialist (CNS)-led ACP session. Using the define, measure, analyze, improve, and control (DMAIC) process of quality improvement methodology, an interprofessional team led by a palliative CNS fostered practice change by (a) incorporating a patient self-administered Supportive Care and Communication Questionnaire (SCCQ) to standardize the ACP assessment, (b) creating an EHR nursing and provider documentation template, (c) offering advanced cancer patients a palliative CNS consultation for ACP review and advance directive completion, and (d) evaluating patients' DCS through the four-item SURE tool. Of 126 participants provided with the SCCQ, 90 completed the document, resulting in a 71% return rate. Among the completed SCCQs, 37% (n = 33) requested a CNS consultation, with 76% (n = 25) returning for the ACP session. The CNS intervention yielded an average reduction of 1.4 points in SURE tool findings, a statistically significant decrease determined by a paired sample t-test. The project's interprofessional collaboration promoted a system-wide standardized ACP process throughout ambulatory, acute, and post-hospital settings.

Understanding the experience of nursing students' internship at a palliative care unit: A phenomenological research study

BACKGROUND

Palliative care is characterised as a holistic, interdisciplinary and humanised approach to care. It transcends the traditional bio-medical perspective in health through a bio-psycho-social and spiritual approach. Holistic point of view in palliative care is essential, and needs to be consistently hi-lighted to nursing students to improve end of life care.

OBJECTIVE

To describe nursing students' experience in a palliative care unit in Santiago, Chile.

DESIGN

A qualitative phenomenological study utilising purposive sampling of 10 nursing students from a Chilean university was undertaken, who completed their final year in a palliative care unit between 2017 and 2019.

METHODS

Data were collected using in-depth interviews, which were conducted, recorded, transcribed and analysed according to Streubert-Carpenter method. This study was approved by the Ethics Committee of Universidad de los Andes, Chile.

RESULTS

Three main themes were identified in the data with their consequent units of meaning; these were experiences from all participants. The first theme identified was the diverse learning experiences students had. Topics included were: spirituality, dignity, teamworking and communication with the patient and family. They also identified personal growth. The second theme was living through the experience of difficult times; this included how they dealt facing death and how they found meaning on this. Also, patient loneliness, abandonment and the impact of shortage of human and material resources. The final theme was recognising that touching patients is often the essence of nursing and is paramount in palliative care.

CONCLUSIONS

Completing a placement in a palliative care unit contributes to student nurses' personal and professional development. It provides multiple tools related to the care of terminally-ill patients and their families. It is recommended to undergraduate nurses have the opportunity to experience palliative care throughout curriculum and that they learn to embed theory to practice.

Adolescents and Young Adults Living With an Uncertain or Poor Cancer Prognosis: The "New" Lost Tribe

Historically, adolescent and young adult (AYA) patients with cancer, diagnosed for the first time at age 15 through 39 years, have often been identified as a "lost tribe" without a medical "home"; neither pediatric nor adult oncology services were able to provide age-appropriate care to this specific group. Internationally, AYA care programs are being established to bridge the gap between the age-defined healthcare worlds and to address the specific needs of AYAs with cancer. However, AYA care programs mostly focus on improving cure rates and addressing survivorship issues, and direct less attention to the unique needs of those living with an uncertain and/or poor cancer prognosis. Additionally, palliative care services are typically poorly equipped to address the age-specific needs of this group. Given that increasingly more AYAs with an uncertain and/or poor cancer prognosis are gaining life years because of novel treatments, and sometimes even face the prospect of long-term disease control, AYA care programs should address the unique palliative care needs of this "new" lost tribe within AYA oncology. This report provides a definition and description of the AYA population living with an uncertain and/or poor cancer prognosis in terms of epidemiologic, clinical, and psychosocial characteristics and challenges, and provides perspectives for future research and care initiatives. It also highlights the need to comprehensively examine the experience of AYAs who are living with uncertain and/or poor cancer prognosis to adjust best care practices for this unique group.

'The experience of spirituality in family caregivers of adult and elderly cancer patients receiving palliative care: A meta-synthesis'

INTRODUCTION

Spirituality is a multidimensional aspect of human experience. In the context of palliative care, it is an individual resource that can be used to cope with illness and to assign new meanings to suffering. Qualitative studies that aim to investigate the experience of spirituality and the needs of family caregivers in this context are rare.

OBJECTIVE

This meta-synthesis aimed to synthesise qualitative studies on the experience of spirituality in family caregivers of adult and elderly cancer patients receiving palliative care.

METHODS

A systematic review was performed in six databases, and 14 studies were included in this meta-synthesis.

RESULTS

The results are presented as a thematic synthesis divided into two analytical themes: (1) The interweaving of spirituality with end-of-life care and (2) The dimensions of suffering and spirituality in the dying process of the loved one. Each analytical theme is explained by two descriptive themes. The results showed that family caregivers express their spirituality in a multidimensional way, giving meaning to the care provided and reassessing the meanings of their lives and their suffering.

CONCLUSION

Investigating the suffering and spiritual needs of family members in this context may be of value to inform comprehensive and multi-professional psychosocial care.

Sobrecarga y calidad de vida de cuidadores de personas con cáncer en cuidados paliativos

Introducción. El cuidador familiar experimenta en muchos casos sobrecarga relacionada con asumir el cuidado de una persona, esto a su vez puede tener implicaciones para su calidad de vida. El objetivo de este estudio fue describir las asociaciones entre el nivel de sobrecarga del cuidado y la calidad de vida de cuidadores de pacientes con cáncer en cuidados paliativos que asistían a una institución de IV nivel de la ciudad de Medellín, Colombia. Materiales y métodos. Estudio descriptivo correlacional de corte transversal desarrollado con 62 cuidadores familiares. Se aplicaron los cuestionarios de caracterización del participante, escala de sobrecarga del cuidador Zarit y calidad de vida del cuidador. Se realizaron pruebas de correlación por coeficiente de Pearson y modelo de regresión simple. Resultados. Se encontró un coeficiente de Pearson de r = -0.54 con una p < 0.0001 entre la sobrecarga y la calidad de vida; surgieron además correlaciones negativas entre todas dimensiones de calidad de vida y la sobrecarga del cuidado. Se estableció un modelo de regresión en el que la sobrecarga del cuidador (b = -0.556 IC 95% = -3.114 - -1.237) y el ser cuidador casado o en unión libre (b = 0.258 IC 95%= 0.907-52.99) son variables predictoras de la calidad de vida. Conclusiones. Existe una correlación inversa y fuerte entre la sobrecarga y la calidad de vida del cuidador familiar de la persona con cáncer en cuidados paliativos.

EXPERIENCE OF FAMILIES FACING CANCER IN PALLIATIVE CARE

ABSTRACT Objective: to understand the experience of families facing cancer in palliative care of one of its members. Method: this is a qualitative research based on the theoretical-methodological framework of Grounded Theory. Six families participated, totaling 15 people. Data were collected from January to December 2019 in the homes of families in a municipality in southern Brazil, through an in-depth interview with the construction of a genogram. Analysis followed the constant comparative method steps: open, selective and theoretical coding. Results: the concepts discovering cancer; suffering with the reality imposed by the illness; preparing to face illness; deciding on treatment; facing the finitude of life, they are part of the central category “Living one day at a time”, which symbolically defines families’ experiences. The substantive theory elaborated shows that the definitions, actions and strategies adopted by families, in family dynamics and in interpersonal interactions, along a trajectory that culminates in the terminality of a relative’s life, is permeated by hope maintenance. Conclusion: throughout the illness experience, families promote changes in their daily lives and in family dynamics, undergoing adaptations and using their internal strengths in an attempt to re-establish the balance prior to the disease. Families live with uncertainty about the future, but it is the hope that drives them to live one day at a time.

Exploring the Experiences of People Treated With Immunotherapies for Advanced Melanoma and Those Caring for Them: "Real-World" Data

BACKGROUND

Recent advances in the development of immunotherapy drugs have resulted in durable responses and improved overall survival for a proportion of patients with advanced melanoma; however, toxicities can be potentially life-threatening. The patients' family and friends (carers) are relied upon to support patients at home post treatment; however, we know little about their experiences.

OBJECTIVES

This study aimed to understand the experiences of patients with advanced melanoma who received immunotherapy and their carers; and to explore the impact of immunotherapy treatment on patients' and carers' quality of life (QoL).

METHODS

A cross-sectional, exploratory design was employed. Semi-structured interviews were conducted with patients: diagnosed with stage IV melanoma, attending an Australian public cancer hospital, had completed or were receiving treatment with immunotherapies; and the people caring for them at home.

RESULTS

Patients (n = 22) described how immunotherapy impacted emotional health, functional ability; and had damaging economic consequences. Fatigue was reported consistently as having a considerable negative influence across all domains of QoL. Carers (n = 9) were anxious about their ability to correctly identify, report and manage side effects at home.

CONCLUSIONS

Results demonstrate how immunotherapy can impact the QoL of both patients and carers, either directly through toxicities or indirectly through mechanisms such as stress, financial toxicity, or fatigue that limits participation in life activities.

IMPLICATIONS FOR PRACTICE

Supportive care resources and interventions are needed for those receiving immunotherapy to minimise negative impacts on QoL. Carers likewise require better preparation and information to assist in identifying potential treatment toxicities and ensure patient safety.

Patient's experiences of suffering across the cancer trajectory: A qualitative systematic review protocol

AIM

To identify, appraise and synthesize the available evidence from qualitative research exploring the suffering of patients with cancer during their illness trajectories.

DESIGN

Protocol for a qualitative systematic review.

DATA SOURCES

The database will include PubMed, CINAHL and Psych Info were searched in May 2020.

METHODS

The review protocol has been registered in International Prospective Register for Systematic Review (CRD42020165405). This review will systematically search qualitative research studies in databases from 1982-May 2020, with predetermined search terms. Searches are limited to studies in English. Two reviewers will independently appraise the methodological quality of the selected studies using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Disagreements can be settled through discussion which includes a third reviewer, if necessary. This review will use the meta-aggregative approach to analyze and synthesize data. A summary of findings from selected studies will be presented.

DISCUSSION

Suffering is a complex dimension that included physical psychological, existential and social dimensions. This review will enable nurses to gain an in-depth understanding of suffering that not only worsens at the end of life that can deliver comprehensive care.

IMPACT

This review is designed to systematically identify and explore the suffering that patients with cancer experience during their illness trajectory. Often suffering is highlighted at the end of life phase. This review will synthesize the evidence of suffering from the beginning of the patient's diagnosis to the end of life. The results of this review provide evidence to support nursing developments in education and clinical practice so that understanding of cancer can be optimized. The findings of the proposed review will contribute as a basis for recommendations for future research regarding suffering.

The role of psychosocial support in the experiences of people living with advanced cancer: A qualitative exploration of patients' perspectives

BACKGROUND

People living with advanced cancer experience significant distress and reduced quality of life due to their symptom burden and life-limiting prognosis. Limited qualitative research has investigated their experiences accessing psychosocial supportive care, and how it meets their needs.

AIM

To explore patients' perspectives of the role of psychosocial support in their experiences of living with advanced cancer.

METHODS

This study used an exploratory qualitative research design and drew upon a social constructionist interpretive framework. Semi-structured interviews were conducted with 23 participants. Participants were asked about their experiences accessing and using psychosocial support following their diagnosis. Audio-recorded interviews were transcribed and analysed using deductive thematic analysis.

RESULTS

The following six themes can be used to describe participants' experiences with psychosocial support: (1) accessing different types of support, (2) appreciating support, (3) need, (4) difficulties accessing support, (5) knowing about support and (6) asking for support. Sources of psychosocial support included family and friends, health professionals, and psychosocial supportive care services. Not all participants were able to access care that met their needs; barriers included suitability of available support, accessibility and stigma surrounding support use.

CONCLUSION

Participants experienced broad variation in their awareness and access to psychosocial support services to meet their needs. Providers of psychosocial supportive care for advanced cancer patients need to consider service accessibility issues. Future psychosocial interventions targeting people living with advanced cancer should consider these issues during development and implementation.

Managing daily life among people with advanced cancer living at home: Responding to uncertainties related to shifting abilities, home care, and treatment

Introduction

People with advanced cancer are increasingly expected to live at home and manage the consequences of illness and treatment. The purpose of this study was to explore how people with advanced cancer manage the influence of home care and treatment on occupations and habits.

Method

Constructivist grounded theory guided the collection and analysis of data from 22 people with advanced cancer. Data were collected using in-depth interviews and participant diaries.

Findings

Uncertainty about abilities to engage in occupation and home care and treatment delivery disrupted participants’ daily life. Participants employed various strategies to manage uncertainties and to preserve a sense of agency and control.

Conclusions

This study provides insights into how people with advanced cancer manage and respond to the impact of illness, home care, and treatment in their daily life. The findings may aid occupational therapists to develop and deliver interventions that allow their patients to maintain a sense of agency in their daily life.

Uncertainty Towards the Disease of Family Caregivers of Patients in Palliative Care: A Scoping Review

Objective: To know the development of the scientific evidence on the uncertainty towards the disease of family caregivers of patients in palliative care. Materials and methods: A descriptive scoping review. A search was conducted in the Embase, ScienceDirect, Medline, Academic Search Complete, Scopus databases, during the 2000-2019 period. The following MeSH terms were used: uncertainty, palliative care, end of life, nursing and caregiver. Fifty articles were selected after the criticism process. Results: Five thematic nuclei emerged: characterization of uncertainty in the caregiver, factors influencing uncertainty, resources to manage uncertainty, uncertainty assessment, and therapies and interventions to approach uncertainty. The higher scale of evidence is found in the characterization of uncertainty in the caregiver, and the voids direct the development of Nursing interventions on the uncertainty of the caregivers of individuals in palliative care. Conclusions: Although the factors influencing uncertainty towards the disease of the caregiver are widely explored, the evidence on the interventions that may help to reduce uncertainty towards the disease is still limited.

Coping by metaphors: the versatile function of metaphors in blogs about living with advanced cancer

Living with a life-limiting cancer illness can entail a turmoil of feelings such as constant fear of loss, suffering and dying. Because patients live longer with life-limiting illness, there is a need for enhanced understanding of how people make sense of and cope with the complicated aspects that this life situation brings on. In this article, we explore how bloggers with advanced cancer use metaphors as ways of making sense of their experiences. Our study is theoretically grounded in Conceptual Metaphor Theory, where metaphors are seen as a powerful phenomenon that both reflects and affects our thinking. The data consist of a corpus of blogs written in Swedish by individuals with advanced cancer, and the findings from our linguistic metaphor analysis are consistently interpreted against the backdrop of literature on coping. Our study thus highlights the intersection of linguistic metaphor analysis and psychological theories of coping by illustrating the many and complex functions metaphors can have as part of sense-making processes. Our hermeneutic approach enables us to show some differences among the three most pervasive metaphor domains in our material, battle, journey and imprisonment: the journey and imprisonment domains are more flexible than the battle domain in terms of the different kinds of coping strategies that are actualised by the bloggers' use of metaphors. One particular finding from our analysis is the way in which the bloggers make use of metaphors to compartmentalise experiences and emotions. Our contention is that careful attention to the metaphors used by patients can improve communication in healthcare and enhance understanding of the complex role language use plays in coping processes more generally. By highlighting the relation between metaphor use and coping, our analysis also provides a way to discuss coping strategies based on the patient's own use of language.

People With Advanced Cancer: The Process of Living Well With Awareness of Dying

Literature suggests that it is possible to live well with advanced cancer but little is known about the process. In this article, we present a secondary analysis of experiences of living with advanced cancer (n = 22) that refines the theory of "Living Well with Chronic Illness" for a different context and population. The refined theory explains the experience of living well with advanced cancer illuminating a five-phase iterative process: struggling, accepting, living with advanced cancer, sharing the illness experience, and reconstructing life. These five phases revolve around the core concept of Awareness of Dying, which varied from awareness of the possibility of dying, to accepting the possibility of dying, to acceptance that "I am dying." Awareness of Dying led to a focus on living well with advanced cancer and movement towards living a life rather than living an illness.

Living in the moment for people approaching the end of life: A concept analysis

BACKGROUND

'Living in the moment' is an essential part of dignity-conserving practice in end-of-life care settings. Although living in the moment is important for care at the end of life, from the perspective of both the person and their family, there is no clear conceptual understanding of what it represents.

OBJECTIVE

To explore the concept of 'living in the moment' in the context of dignity-conserving care at the end of life.

DESIGN

A concept analysis.

DATA SOURCES

The databases of Medline, CinAHL, PubMed, Web of Science, PsycINFO, SocINDEX and Cochrane were searched for studies published between 1941 and 2019, and searches of dictionaries and grey literature, as well as hand-searching were conducted, to yield qualitative, mixed methods and systematic reviews published in English, related to the term 'living in the moment'.

METHOD

The methods of Walker and Avant were used to identify antecedents, attributes and consequences of the concept of 'living in the moment'.

RESULTS

The literature review generated a total of 37 papers for this concept analysis. The attributes identified were (1) simple pleasure, (2) prioritising relationships, (3) living each day to the fullest, (4) maintaining normality, and (5) not worrying about the future. The antecedents were (1) awareness of dying, (2) living with life-threatening illness, (3) positive individual growth, and (4) living with an uncertain future. The consequences were (1) a good quality of life, (2) preserving dignity, and (3) coping with the uncertainty of life.

CONCLUSIONS

A universal definition and conceptual model of the main concept, including theoretical relationships between its antecedents, attributes and consequences, was developed. The definition and proposed conceptual model can allow instruments to be developed that measure the effects, existence or attributes of the concept, and identify a theoretical model, and can also lead to new perspectives and strategies for implementation by nurses to improve dignified person-centred care at the end of life.

Exercise Behaviors and Fatigue in Patients Receiving Immunotherapy for Advanced Melanoma: A Cross-Sectional Survey via Social Media

Objective: Treatment with immunotherapy has positively changed the long-term outlook of many patients with advanced melanoma; however, fatigue is a common and debilitating side effect. Evidence indicates exercise can improve treatment-related fatigue for patients receiving chemotherapy and radiotherapy. However, currently little is known about exercise behaviors and preferences of patients receiving immunotherapy. This project aimed to describe self-reported levels of fatigue related to immunotherapy; patient perspectives of exercise behaviors; and barriers and facilitators to engagement in exercise for patients receiving, or recently completed immunotherapy for unresectable stage III and stage IV melanoma. Method: A cross-sectional purpose-built survey was distributed to members of the Melanoma Patients Australia closed Facebook group via an online survey platform. The survey remained active for 1 month, with 3 posts during this time inviting members to participate. Results: A total of 55 responses were collected. Just over half the participants (n = 31; 56%) described exercising while receiving immunotherapy, with walking as the most common activity (n = 24; 77%). Participants described a range of physical and emotional benefits of exercise, the most predominant being fatigue reduction. Barriers to exercise also included fatigue and competing physical demands at home or work. Patient understanding of what constitutes exercise appeared to differ from clinical classifications. Conclusions: Results from this study indicate that patients are engaging in exercise while receiving immunotherapy, with the intent of mediating treatment-related fatigue. Identification of preferred exercise activities and barriers will assist in developing tailored exercise interventions for this cohort.

Living with advanced cancer: Rich Pictures as a means for health care providers to explore the experiences of advanced cancer patients

Background

To provide holistic care to patients with advanced cancer, health care professionals need to gain insight in patients’ experiences across the different domains of health. However, describing such complex experiences verbally may be difficult for patients. The use of a visual tool, such as Rich Pictures (RPs) could be helpful. We explore the use of RPs to gain insight in the experiences of patients with advanced cancer.

Methods

Eighteen patients with advanced cancer were asked to draw a RP expressing how they experienced living with cancer, followed by a semi‐structured interview. Qualitative content analysis, including the examination of all elements in the drawings and their interrelationships, was used to analyze the RPs, which was further informed by the interviews.

Results

The RPs clearly showed what was most important to an individual patient and made relations between elements visible at a glance. Themes identified included: medical aspects, the experience of loss, feelings related to loss, support from others and meaningful activities, and integration of cancer in one's life. The added value of RPs lies in the ability to represent these themes in one single snapshot.

Conclusions

RPs allow for a complementary view on the experiences of advanced cancer patients, as they show and relate different aspects of patients’ lives. A RP can provide health care professionals a visual summary of the experiences of a patient. For patients, telling their story to health care professionals might be facilitated when using RPs.

The meaning of dignity when the patients' bodies are falling apart

BACKGROUND

People with advanced cancer disease experience great bodily changes due to disease or treatment. They tend to feel ashamed when their bodies are subjected to such changes and they feel their dignity is threatened.

AIM

To explore the patients' experiences of the bodily changes in relation to dignity.

DESIGN

The study has a hermeneutic qualitative design.

METHOD

Individual in-depth interviews and participant observations were conducted with 13 patients with advanced cancer disease at a hospice inpatient unit in Norway. Gadamer's ontological hermeneutics inspired the interpretation.

RESULTS AND CONCLUSION

The patients' unpredictable, sick bodies forced the patients, or gave them the opportunity, to relate to their bodies in an honest way. The patients, living in interaction between suffering and health, strove to find dignity. The patients had a will to live and they experienced a love in their unruly bodies that both helped alleviate their suffering and give them an experience of enhanced dignity. It is important that nurses have insight into the consequences of bodily changes for the patients' experiences of dignity in health and suffering to provide good, dignified care.

Control and Context Are Central for People With Advanced Illness Experiencing Breathlessness: A Systematic Review and Thematic Synthesis

CONTEXT

Breathlessness is common and distressing in advanced illness. It is a challenge to assess, with few effective treatment options. To evaluate new treatments, appropriate outcome measures that reflect the concerns of people experiencing breathlessness are needed.

OBJECTIVES

The objective of this study was to systematically review and synthesize the main concerns of people with advanced illness experiencing breathlessness to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.

METHODS

This is a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. MEDLINE (1946-2017), PsycINFO (1806-2017), and EMBASE (1974-2017), as well as key journals, gray literature, reference lists, and citation searches, identified qualitative studies exploring the concerns of people living with breathlessness. Included studies were quality-assessed using the Critical Appraisal Skills Program checklist and analyzed using thematic synthesis.

RESULTS

We included 38 studies with 672 participants. Concerns were identified across six domains of "total" breathlessness: physical, emotional, spiritual, social, control, and context (chronic and episodic breathlessness). Four of these have been previously identified in the concept of "total dyspnea." Control and context have been newly identified as important, particularly in their influence on coping and help-seeking behavior. The importance of social participation, impact on relationships, and loss of perceived role within social and spiritual domains also emerged as being significant to individuals.

CONCLUSION

People with advanced illness living with breathlessness have concerns in multiple domains, supporting a concept of "total breathlessness." This adapted model can help to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.

Psychological interventions in palliative care

PURPOSE OF REVIEW

To provide an update on recent studies about psychological interventions in palliative (mainly cancer) care with a focus on physical, psychological, spiritual, and social aspects.

RECENT FINDINGS

Some promising psychological interventions for physical challenges, such as fatigue, pain, dyspnea, and insomnia do exist, but further research is needed. Regarding psychological aspects, current reviews showed small to large effects in the reduction of depression and anxiety symptoms through cognitive behavioral-based interventions, mindfulness-based interventions, and meaning-based interventions. Meaning-based or dignity-based approaches were also used for targeting spiritual aspects or existential distress. Social aspects that play a crucial role in palliative care are addressed by social support interventions, end-of-life discussions, and advanced careplanning. All of these psychological interventions must meet the specific requirements of palliative care, namely abbreviated session time and flexibility concerning locality of interventions, a minimized questionnaire burden and a high attrition rate caused by patients' poor physical conditions or deaths.

SUMMARY

There is substantial research on psychological interventions in palliative care that shows promising results, but sample sizes were often small. Due to its high relevance for this growing patient group, there is a strong need for ongoing/further research.

Effectiveness of palliative care interventions offering social support to people with life-limiting illness-A systematic review

Individuals managing the challenges of life-limiting illness require adequate social support to maintain quality of life. Qualitative research reports that patients value highly the social support obtained in palliative care interventions such as day care and group therapies. This systematic review aims to summarise existing quantitative evidence on palliative care interventions that facilitate social support. Research literature was systematically searched using electronic databases and key journals. Searches returned a total of 6,247 unique titles of which sixteen were eligible for inclusion. Interventions include group therapies, group practical interventions and palliative day care. Outcome measures and study designs were heterogeneous. Only one study used a validated outcome measure of social support. Benefits were influenced by participant characteristics such as baseline distress. Partial economic evaluation was attempted by two studies. Methodological challenges include attrition and use of outcome measures that were insensitive to change. Statistically significant results were reported in psychological and physical domains. Evidence is limited due to methodological issues and a scarcity of quantitative research, particularly regarding long-term benefits and cost-effectiveness. Interventions may be more beneficial to some groups than others.

The paradoxical body: A glimpse of a deeper truth through relatives' stories

BACKGROUND

People with progressive cancer experience that their bodies change due to disease and/or treatment. The body is integral to the unity of the human being, a unity that must be perceived as whole if dignity shall be experienced. Relatives are in touch with the suffering bodies of their dear ones, physically, socially, mentally, and existentially, and thus the relatives' experiences of the bodies of their dear ones might yield insight into the concept of dignity.

AIM

The aim of this study is to explore relatives' experiences of the patients' bodily changes from a perspective of dignity.

RESEARCH DESIGN AND METHOD

A total of 12 relatives from a hospice in Norway were interviewed. Gadamer's ontological hermeneutics inspired the interpretation.

ETHICAL CONSIDERATIONS

The principles of voluntariness, confidentiality, withdrawal, and anonymity were respected during the whole research process. The Norwegian Social Science Data Services approved the study.

RESULTS AND CONCLUSION

The conversations about the body were conversations about ambivalent or paradoxical matters that shed light on the concept of dignity. The results show that the relatives got in touch with elements that otherwise would have remained tacit and unspoken, and which gave glimpses of a deeper truth, which might reveal the core of dignity. Furthermore, the relatives' confirmation of the ambivalence might be understood as a strong ethical obligation to treat the other with dignity. The confirmation may also reveal the relatives' unselfish love of the other, which can be understood as the core of ethics and ethos. Finally, the results reveal the relatives' limited insight into their dear ones' bodily changes, and we discuss the challenges of truly seeing the other. Body knowledge and the relationship between body and dignity as phenomena cannot be ignored and needs more attention and articulation in clinical nursing practice and in nursing research.

Desperately seeking a cure: Treatment seeking and appraisal in irritable bowel syndrome

Objectives

Irritable bowel syndrome (IBS) is common and adversely affects patients' quality of life. Multiple potential treatment options exist for patients (and clinicians) to choose from, with limited evidence to inform treatment selection. The aim was to explore how patients with IBS go about seeking and appraising different treatment modalities, with a view to elucidating the psychological processes involved and identifying opportunities to improve clinical practice.

Design

Qualitative study nested within a randomized controlled trial of therapist‐delivered and web‐based cognitive behavioural therapy versus treatment‐as‐usual for IBS.

Methods

A total of 52 people participated in semi‐structured interviews about their prior experiences of treatments for IBS. Transcripts were analysed using inductive thematic analysis.

Results

Key themes (desperation for a cure, disappointment at lack of cure, appraising the effects of diverse treatments, and hope for positive effects) clustered around an overarching theme of being trapped within a vicious cycle of hope and despair on treatment seeking. A desperation and willingness drove interviewees to try any treatment modality available that might potentially offer relief. Coming to accept there is no cure for IBS helped interviewees escape the vicious cycle. Treatments were appraised for their effects on symptoms and quality of life while also considering, but rarely prioritizing, other aspects including convenience of the regimen itself, whether it addressed the perceived root causes of IBS, perceived side‐effects, and cost.

Conclusion

Treatment seeking in IBS can be challenging for patients. Supportive discussions with health care professionals about illness perceptions, treatment beliefs, and goals could improve patients' experiences.

A concept map of death-related anxieties in patients with advanced cancer

OBJECTIVES

Fear of death and dying is common in patients with advanced cancer, but can be difficult to address in clinical conversations. We aimed to show that the experience of death anxiety may be deconstructed into a network of specific concerns and to provide a map of their interconnections to aid clinical exploration.

METHODS

We studied a sample of 382 patients with advanced cancer recruited from outpatient clinics at the Princess Margaret Cancer Centre, Toronto, Canada. Patients completed the 15-item Death and Dying Distress Scale (DADDS). We used item ratings to estimate a regularised partial correlation network of death and dying-related concerns. We calculated node closeness-centrality, clustering and global network characteristics.

RESULTS

Death-related anxieties were highly frequent, each associated with at least moderate distress in 22%-55% of patients. Distress about 'Running out of time' was a central concern in the network. The network was organised into two areas: one about more practical fears concerning the process of dying and another about more psychosocial or existential concerns including relational problems, uncertainty about the future and missed opportunities. Both areas were yet closely connected by bridges which, for example, linked fear of suffering and a prolonged death to fear of burdening others.

CONCLUSIONS

Patients with advanced cancer may have many interconnected death-related fears that can be patterned in individual ways. The bridging links between more practical and more psychosocial concerns emphasise that the alleviation of death anxiety may require interventions that integrate symptom management, advance care planning and psychological treatment approaches.

Research Roundup

Synopses of a selection of recently published research articles of relevance to palliative care.