1
|
Webb L, Yarwood G, Witham G, Wright S, Galvani S. Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care. BMC Palliat Care 2024; 23:86. [PMID: 38556868 PMCID: PMC10983728 DOI: 10.1186/s12904-024-01416-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/21/2024] [Indexed: 04/02/2024] Open
Abstract
Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.
Collapse
Affiliation(s)
- Lucy Webb
- Manchester Metropolitan University, Oxford Road, Manchester, UK.
| | - Gemma Yarwood
- Manchester Metropolitan University, Oxford Road, Manchester, UK
| | - Gary Witham
- Manchester Metropolitan University, Oxford Road, Manchester, UK
| | - Sam Wright
- Change Grow Live, 76 King Street, Orega, Manchester, UK
| | - Sarah Galvani
- Manchester Metropolitan University, Oxford Road, Manchester, UK
| |
Collapse
|
2
|
Langmann GA, Childers J, Merlin JS. Caring for Patients With Opioid Misuse or Substance Use Disorders in Hospice: A National Survey. J Palliat Med 2024; 27:209-215. [PMID: 37824806 PMCID: PMC11074426 DOI: 10.1089/jpm.2023.0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 10/14/2023] Open
Abstract
Background: Opioid misuse and substance use disorders (SUDs) including opioid use disorder (OUD) are common and negatively impact quality of life. Hospice clinicians' experiences with these conditions have not been well described. Objectives: We sought to explore hospice clinicians' knowledge, practices, and comfort caring for patients with opioid misuse (e.g., a pattern of unsanctioned opioid use escalation, or concurrent illicit substance use) and SUDs. Design: We recruited hospice clinicians in the United States via national hospice and palliative care organizations to complete an online survey designed by the study authors and pilot tested with an interdisciplinary group of current/former hospice clinicians. Results: One hundred seventy-five clinicians (40% nurses, 40% physicians, 16% nurse practitioners) responded to the survey; most had cared for two or more hospice patients with opioid misuse or SUD in the past month. The majority felt confident identifying opioid misuse (94%) and taking SUD histories (79%). Most (62%) felt it is their role to treat hospice patients for SUD, though 56% lacked comfort in using buprenorphine for OUD treatment. While the majority felt it is their role to treat pain in hospice patients with SUDs (94%) and that hospice can help patients with SUDs (94%), many were not comfortable managing pain in patients taking buprenorphine (45%) or naltrexone (49%) for SUDs. Most felt comfortable managing pain in patients taking methadone for SUD (73%). Conclusions: Opioid misuse and SUD are common in hospice. Though clinicians are comfortable taking relevant histories, they feel less comfortable managing patients' opioid misuse or SUD, or these patients' pain.
Collapse
Affiliation(s)
- Gabrielle A. Langmann
- Supportive and Palliative Care Program, Division of General Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Rintoul K, Song E, McLellan-Carich R, Schjelderup ENR, Barr AM. A scoping review of psychiatric conditions associated with chronic pain in the homeless and marginally housed population. FRONTIERS IN PAIN RESEARCH 2023; 4:1020038. [PMID: 37187857 PMCID: PMC10175796 DOI: 10.3389/fpain.2023.1020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
The present review sought to examine and summarise the unique experience of concurrent pain and psychiatric conditions, that is often neglected, within the population of homeless individuals. Furthermore, the review examined factors that work to aggravate pain and those that have been shown to improve pain management. Electronic databases (MEDLINE, EMBASE, psycINFO, and Web of Science) and the grey literature (Google Scholar) were searched. Two reviewers independently screened and assessed all literature. The PHO MetaQAT was used to appraise quality of all studies included. Fifty-seven studies were included in this scoping review, with most of the research being based in the United States of America. Several interacting factors were found to exacerbate reported pain, as well as severely affect other crucial aspects of life that correlate directly with health, within the homeless population. Notable factors included drug use as a coping mechanism for pain, as well as opioid use preceding pain; financial issues; transportation problems; stigma; and various psychiatric disorders, such as post-traumatic stress disorder, depression, and anxiety. Important pain management strategies included cannabis use, Accelerated Resolution Therapy for treating trauma, and acupuncture. The homeless population experiences multiple barriers which work to further impact their experience with pain and psychiatric conditions. Psychiatric conditions impact pain experience and can work to intensify already adverse health circumstances of homeless individuals.
Collapse
Affiliation(s)
- Kathryn Rintoul
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Esther Song
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
- Department of Psychiatry, Faculty of Medicine, UBC, Vancouver, BC, Canada
| | - Rachel McLellan-Carich
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Elizabeth N. R. Schjelderup
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Alasdair M. Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
- Correspondence: Alasdair M. Barr
| |
Collapse
|
4
|
Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med 2022; 37:2821-2833. [PMID: 35534663 PMCID: PMC9411356 DOI: 10.1007/s11606-022-07618-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
Collapse
Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Jones
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Alisa Patten
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Roberts
- NYU Health Sciences Library, New York University Grossman School of Medicine, New York, NY, USA
| | - P Todd Korthuis
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
5
|
When “Good Enough” Isn’t Good Enough: Interdisciplinary Perspectives on Caring for Adults Using Substances at the End of Life. Int J Ment Health Addict 2022. [DOI: 10.1007/s11469-020-00445-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractThis paper draws on data from one strand of a six-strand, exploratory study on end of life care for adults using substances (AUS). It presents data from the key informant (KI) strand of the study that aimed to identify models of practice in the UK. Participant recruitment was purposive and used snowball sampling to recruit KIs from a range of health and social care, policy and practice backgrounds. Data were collected in 2016–2017 from 20 KIs using a semi-structured interview approach. The data were analysed using template analysis as discussed by King (2012). This paper focusses on two of seven resulting themes, namely “Definitions and perceptions of key terms” in end of life care and substance use sectors, and “Service commissioning and delivery.” The KIs demonstrated dedicated individual practice, but were critical of the systemic failure to provide adequate direction and resources to support people using substances at the end of their lives.
Collapse
|
6
|
Rowley J, Richards N, Carduff E, Gott M. The impact of poverty and deprivation at the end of life: a critical review. Palliat Care Soc Pract 2021; 15:26323524211033873. [PMID: 34541536 PMCID: PMC8442481 DOI: 10.1177/26323524211033873] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.
Collapse
Affiliation(s)
- Jane Rowley
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Naomi Richards
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | | | - Merryn Gott
- Professor, Te Ārai Palliative Care and End of
Life Research Group, School of Nursing, The University of Auckland, Private
Bag 92019, Auckland 1142, New Zealand
| |
Collapse
|
7
|
Galvani S. Offering the best death possible: supporting people using substances at the end of life. Addiction 2020; 115:391-392. [PMID: 31400175 PMCID: PMC7027735 DOI: 10.1111/add.14779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/30/2022]
|
8
|
Ebenau A, Dijkstra B, ter Huurne C, Hasselaar J, Vissers K, Groot M. Palliative care for patients with substance use disorder and multiple problems: a qualitative study on experiences of healthcare professionals, volunteers and experts-by-experience. BMC Palliat Care 2020; 19:8. [PMID: 31937289 PMCID: PMC6961318 DOI: 10.1186/s12904-019-0502-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 12/08/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is little information about how healthcare professionals feel about providing palliative care for patients with a substance use disorder (SUD). Therefore, this study aims to explore: 1) the problems and needs experienced by healthcare professionals, volunteers and experts-by-experience (HCP/VE) during their work with patients with SUD in a palliative care trajectory and; 2) to make suggestions for improvements using the quality of care model by Donabedian (Structure, Process, Outcome). METHODS A qualitative study was conducted, consisting of six focus group interviews which consisted of HCP/VE working with patients with SUD in a palliative care phase. At the end of the focus group interviews, participants structured and summarized their experiences within a Strengths, Weaknesses, Opportunities and Threats (SWOT) framework. Interview transcripts (other than the SWOT) were analysed by the researchers following procedures from the Grounded Theory Approach ('Grounded Theory Lite'). SWOT-findings were not subjected to in-depth analysis. RESULTS HCP/VE stated that within the Structure of care, care networks are fragmented and HCP/VE often lack knowledge about patients' multiplicity of problems and the time to unravel these. Communication with this patient group appears limited. The actual care-giving Process requires HCP/VE a lot of creativity and time spent seeking for cooperation with other caregivers and appropriate care settings. The latter is often hindered by stigma. Since no formalized knowledge is available, care-delivery is often exclusively experience-based. Pain-medication is often ineffective due to active substance use. Finally, several Outcomes were brought forward: Firstly, a palliative care phase is often identified only at a late stage. Secondly, education and a (mobile) team of expertise are desired. Thirdly, care for the caregivers themselves is often de-prioritized. CONCLUSIONS Better integration and collaboration between the different professionals with extensive experience in addiction, palliative and general curative care is imperative to assure good palliative care for patients with SUD. Currently, the resources for this care appear to be insufficient. Development of an educational program and social mapping may be the first steps in improving palliative care for patients with severe SUD.
Collapse
Affiliation(s)
- Anne Ebenau
- Department of Anesthesiology, Pain and Palliative Care, Radboudumc Expertise centre for Pain and Palliative Medicine, Internal Post 549, Radboud University Medical Centre (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Salvation Army, Central Netherlands, Zandvoortweg 211, 3741 BE Baarn, The Netherlands
| | - Boukje Dijkstra
- Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Postbus 9104, 6500 HE Nijmegen, The Netherlands
| | - Chantal ter Huurne
- Tactus Addiction Care, Lokatie Ripperdastraat, Ripperdastraat 8, 7511 JR Enschede, The Netherlands
| | - Jeroen Hasselaar
- Department of Anesthesiology, Pain and Palliative Care, Radboudumc Expertise centre for Pain and Palliative Medicine, Internal Post 549, Radboud University Medical Centre (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Care, Radboudumc Expertise centre for Pain and Palliative Medicine, Internal Post 549, Radboud University Medical Centre (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Marieke Groot
- Department of Anesthesiology, Pain and Palliative Care, Radboudumc Expertise centre for Pain and Palliative Medicine, Internal Post 549, Radboud University Medical Centre (Radboudumc), P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
9
|
Witham G, Yarwood G, Wright S, Galvani S. An ethical exploration of the narratives surrounding substance use and pain management at the end of life: a discussion paper. Nurs Ethics 2019; 27:1344-1354. [PMID: 31526085 PMCID: PMC7406987 DOI: 10.1177/0969733019871685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This discussion article examines narrative positioning related to pain management for people who use substances at the end of life. We explore how dominant narrative genres associated with biomedicine, such as ‘restitution’ and narratives common within the context of drug services such as ‘recovery’ can hinder effective pain management within this population. We argue that these discourses can marginalise the ethical self-identity of patients who use substances at the end of life. It can also trouble health and social care professionals in supporting patients and generating counter-narratives that challenge those often associated with substance use. Stigma is a common experience for this population with stereotyping as ‘junkies’ and associated with criminality. They are positioned as drug-seeking, and this requires more surveillance at the end of life when opioid therapy is potentially more available and authorised. This can make it challenging to generate ‘companion’ stories that are positive and maintain moral adequacy. Dominant biomedical narrative genres often prevent the recognition of the fractured stories that people using substances can often present with. This can lead to narrative silencing and to the under treatment of pain. The person’s self-identity is invested in narratives of recovery, and opioid use symbolises their addicted past because for practitioners, this population is at clinical risk with the potential for drug seeking behaviours. Whilst not requiring formal ethical review this discussion paper was constructed in accordance with good scientific practice with the work of other researchers respected and cited appropriately.
Collapse
|