End-of-life preferences in advanced cancer patients willing to discuss issues surrounding their terminal condition

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

BACKGROUND

Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway.

METHOD

From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team.

RESULTS

A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance.

CONCLUSION

With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Revie ⊕: Impact of a resource-based life review intervention on patients with advanced cancer: A waitlist controlled trial

PURPOSE

Life review interventions aim to support individuals facing an incurable disease accompanied by existential concerns and health-related challenges. Based on encouraging feasibility results, this study assessed the effects of Revie ⊕ life review intervention on the self-esteem of patients with advanced cancer, and the effects on well-being, post-traumatic growth, life satisfaction, symptom burden and interaction with nurses.

METHOD

The study consisted of a two-arm parallel-group, waitlist-controlled trial (WCT) in the oncology division of a Swiss-French University Hospital. Revie ⊕ was composed of nurse-led meeting with the patient to address and document significant life events using a strengths-focused approach and targeting the life project.

RESULTS

Due to Covid-19 pandemic, adjustments were made regarding study duration and participant's allocation: Fifty-eight patients received Revie ⊕, 39 completed all the measurements. Self-esteem was high at baseline and maintained stability over time. The social well-being decreased in the intervention group before-after Revie ⊕ (-1.7 (3.9), p = 0.044) while emotional and functional well-being showed stability. The intensity of symptoms decreased in the intervention group before-after Revie ⊕: 4.9 (9.4), p = 0.020.

CONCLUSIONS

This study suggests that patients living with an advanced cancer and who received Revie ⊕ intervention may have maintained their self-esteem high over time. Observed results are promising, particularly considering the influence of the pandemic. Nevertheless, these findings do not allow us to draw definitive conclusions regarding the efficacy of the intervention on self-esteem. WCT seems not to be the appropriate design to highlight the added value of Revie ⊕ for this particularly vulnerable population.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04254926.

Clinician Trust in Artificial Intelligence: What is Known and How Trust Can Be Facilitated

Predictive analytics based on artificial intelligence (AI) offer clinicians the opportunity to leverage big data available in electronic health records (EHR) to improve clinical decision-making, and thus patient outcomes. Despite this, many barriers exist to facilitating trust between clinicians and AI-based tools, limiting its current impact. Potential solutions are available at both the local and national level. It will take a broad and diverse coalition of stakeholders, from health-care systems, EHR vendors, and clinical educators to regulators, researchers and the patient community, to help facilitate this trust so that the promise of AI in health care can be realized.

End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death

There is limited knowledge regarding Colombian patients with advanced cancer preferences regarding their final moments, place of death, and post-death wishes. To better understand these preferences, we conducted 23 in-depth interviews with patients between the ages of 28 and 78 receiving treatment at two academic hospitals and the National Cancer Institute. While many participants desired a peaceful death, few were comfortable discussing the topic of death directly. Some younger participants expressed an interest in euthanasia but had not received any guidance or support. While several participants preferred a home death, some expressed a desire to die in a hospital due to better symptom control. Additionally, when discussing post-death wishes, some participants expressed frustration about being unable to have these conversations with their loved ones and their preferences for funeral arrangements. Socioeconomic and geographical factors significantly impacted the wishes and preferences expressed, with many individuals hesitant to initiate difficult conversations.

Interdisciplinary collaboration in serious illness conversations in patients with multiple myeloma and caregivers - a qualitative study

BACKGROUND

There is growing evidence that conversations between healthcare professionals and patients with serious illness can improve the quality of end-of-life cancer care. Yet, there is lack of insight into how different healthcare professions collaborate to deliver serious illness communication, as well as patients' and caregivers' perceptions of this collaboration between the nurse and physician. This study explores the interdisciplinary collaboration between nurses and physicians in serious illness conversations with patients diagnosed with multiple myeloma and their caregivers.

METHODS

Eleven dyadic interviews were conducted with 22 patients and caregivers, and two focus group interviews involving four nurses and the other with four physicians. Data analysis and reporting were conducted using reflexive thematic analysis within phenomenological epistemology.

RESULTS

The interdisciplinary collaboration was characterized by three main themes: (1) Importance of relationships, (2) Complementary perspectives, and (3) The common goal.

CONCLUSION

This study highlights the importance of interdisciplinarity in serious illness conversations as it enhances the use of existential and descriptive language when addressing medical, holistic, and existential issues. The use of broader language also reflects that interdisciplinary interaction strengthens the expertise of each professional involved in patient care. Through interdisciplinary collaboration, the preferences, hopes, and values of the patient and caregiver can be integrated into the treatment plan, which is key in providing the delivery of optimal care. To promote cohesive and coordinated collaboration, organizational changes are recommended such as supporting continuity in patient-healthcare professional relationships, providing interdisciplinary training, and allocating time for pre-conversation preparation and post-conversation debriefing.

Cancer patients spend more time at home and more often die at home with advance care planning conversations in primary health care: a retrospective observational cohort study

Background

Spending time at home and dying at home is advocated to be a desirable outcome in palliative care (PC). In Norway, home deaths among cancer patients are rare compared to other European countries. Advance care planning (ACP) conversations enable patients to define goals and preferences, reflecting a person’s wishes and current medical condition.

Method

The study included 250 cancer patients in the Romsdal region with or without an ACP conversation in primary health care who died between September 2018 and August 2020. The patients were identified through their contact with the local hospital, cancer outpatient clinic or hospital-based PC team.

Results

During the last 90 days of life, patients who had an ACP conversation in primary health care (N=125) were mean 9.8 more days at home, 4.5 less days in nursing home and 5.3 less days in hospital. Having an ACP conversation in primary health care, being male or having a lower age significantly predicted more days at home at the end of life (p< .001). Patients with an ACP conversation in primary health care where significantly more likely to die at home (p< .001) with a four times higher probability (RR=4.5). Contact with the hospital-based PC team was not associated with more days at home or death at home. Patients with contact with the hospital-based PC team were more likely to have an ACP conversation in primary health care.

Conclusion

Palliative cancer patients with an ACP conversation in primary health care spent more days at home and more frequently died at home. Data suggest it is important that ACP conversations are conducted in primary health care setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00952-1.

Knowledge, attitudes and preferences of palliative and end-of-life care among patients with cancer in mainland China: a cross-sectional study

OBJECTIVES

This study aimed to investigate the knowledge and attitudes of patients with cancer of palliative care and their preferences regarding end-of-life care in mainland China.

DESIGN

A cross-sectional study.

SETTING

This study was conducted in a tertiary cancer hospital.

PARTICIPANTS

Two hundred forty-seven patients with cancer were recruited and consented to fill out the questionnaires.

OUTCOME MEASURES

The participants' knowledge and attitudes of palliative care and their preferences of end-of-life care involving place of care, place of death, truth disclosure and treatments during end-of-life were measured.

RESULTS

In total, 239 questionnaires were valid. The vast majority of patients with cancer (81.2%) had never heard about palliative care or related policies, and only a few of them (5.8%) had somewhat or totally understanding of palliative care. Most participants (75.3%) had supportive attitudes towards palliative care. In terms of preferences for end-of-life care, most patients with cancer preferred to be cared for at home at the end of their life and to die at home. The majority of patients with cancer (65.7%) wanted to know their diagnosis or prognosis of the disease, regardless of the type of disease. More than half of the participants (54%) wished to improve their quality of life rather than prolong their life expectancy. More than a third of the patients with cancer preferred to entrust a family member or agent to sign medical decision agreements for them.

CONCLUSIONS

It is essential for healthcare providers to improve the understanding of patients with cancer of palliative care and be aware of the end-of-life care preferences of patients with cancer, in order to provide support that enables patients with cancer to receive end-of-life care that is accordant with their wishes.

Healthcare professionals' perspectives of patient and family preferences of patient place of death: a qualitative study

BACKGROUND

Home death is one of the key performance indicators of the quality of palliative care service delivery. Such a measure has direct implications on everyone involved at the end of life of a dying patient, including a patient's carers and healthcare professionals. There are no studies that focus on the views of the team of integrated inpatient and community palliative care service staff on the issue of preference of place of death of their patients. This study addresses that gap.

METHODS

Thirty-eight participants from five disciplines in two South Australian (SA) public hospitals working within a multidisciplinary inpatient and community integrated specialist palliative care service, participated in audio-recorded focus groups and one-on-one interviews. Data were transcribed and thematically analysed.

RESULTS

Two major and five minor themes were identified. The first theme focused on the role of healthcare professionals in decisions regarding place of death, and consisted of two minor themes, that healthcare professionals act to: a) mediate conversations between patient and carer; and b) adjust expectations and facilitate informed choice. The second theme, healthcare professionals' perspectives on the preference of place of death, comprised three minor themes, identifying: a) the characteristics of the preferred place of death; b) home as a romanticised place of death; and c) the implications of idealising home death.

CONCLUSION

Healthcare professionals support and actively influence the decision-making of patients and family regarding preference of place of death whilst acting to protect the relationship between the patient and their family/carer. Further, according to healthcare professionals, home is neither always the most preferred nor the ideal place for death. Therefore, branding home death as the ideal and hospital death as a failure sets up families/carers to feel guilty if a home death is not achieved and undermines the need for and appropriateness of death in institutionalised settings.

Hospice Patient Care Goals and Medical Students' Perceptions: Evidence of a Generation Gap?

BACKGROUND

The ability to perceive care goals of the dying may be an indicator of future quality patient-centered care. Research conducted on end-of-life goals indicates discrepancies between patients and physicians.

OBJECTIVE

The aim of this study is to compare end-of-life care goals of hospice patients and medical student perceptions of patient care goals.

DESIGN

Hospice patients and medical students were surveyed on their care goals and perceptions, respectively, using an 11-item survey of goals previously identified in palliative care literature. Medical student empathy was measured using the Interpersonal Reactivity Index.

SETTINGS/PARTICIPANTS

Eighty hospice patients and 176 medical students (97 first-year and 79 third-year) in a New York State medical school.

RESULTS

Medical students ranked 7 of the 11 care goals differently than hospice patients: not being a burden to family (p < .001), time with family and friends (p = .002), being at peace with God (p < .001), dying at home (p = .004), feeling that life was meaningful (p < .001), living as long as possible (p < .001), and resolving conflicts (p < .001). Third-year students were less successful than first-year students in perceiving patient care goals of hospice patients. No significant differences in medical student empathy were found based on student year.

CONCLUSIONS

Medical students, while empathetic, were generally unsuccessful in perceiving end-of-life care goals of hospice patients in the psychosocial and spiritual domains. Differences impeding the ability of medical students to understand these care goals may be generationally based. Increased age awareness and sensitivity may improve future end-of-life care discussions. Overall, there is a need to recognize the greater dimensionality of the dying in order to provide the most complete patient-centered care.

Identifying End-of-Life Preferences Among Chinese Patients With Cancer Using the Heart to Heart Card Game

Background:

Understanding the preferences for end-of-life (EOL) care is imperative in providing quality care to patients with life-threatening illness. However, it is difficult for patients, families, and health-care providers to initiate EOL conversations in China. An easy-to-use tool that could help health-care providers initiate EOL discussions is the Heart to Heart Card Game (HHCG), originally designed for Chinese Americans.

Objective:

To evaluate the EOL preferences among Chinese patients with cancer using the HHCG.

Methods:

We conducted a descriptive study to assess EOL preferences using HHCG among patients at the oncology chemoradiotherapy department of a Chinese tertiary hospital.

Results:

We recruited 58 patients in total of which 40 (69%) patients completed HHCG. The most frequently selected card was “I want my family to get along,” followed by “I don’t want to be a burden to my family,” and “I want to maintain my dignity.” Among the 3 cards selected, social needs were rated as the most important (36.7%), followed by spiritual needs (35.8%), physical needs (20.0%), and financial needs (7.5%). The evaluation of the HHCG revealed that more than 70% of the participants highly valued HHCG.

Conclusion:

The HHCG can be used as a communication tool to encourage EOL discussions between cancer patients and health-care providers in China. Moreover, Chinese patients with cancer attach significant importance to their family and maintaining dignity at the EOL.

Patients' Autonomy at the End of Life: A Critical Review

CONTEXT

The predominating definition of autonomy as a capacity to make an independent rational choice may not be suitable for patients in palliative care. Therefrom arises the actual need for more contextualized perspectives on autonomy to promote the quality of life and satisfaction with care of terminally ill patients.

OBJECTIVES

This review aimed to develop a theoretical structural model of autonomy at the end of life based on patients' end-of-life care preferences.

METHODS

In this review, we used systematic strategy to integrate and synthesize findings from both qualitative and quantitative studies investigating patients' view on what is important at the end of life and which factors are related to autonomy. A systematic search of EMBASE (OVID), MEDLINE (OVID), Academic Search Complete (EBSCO), CINAHL (EBSCO), and PsycINFO (EBSCO) was conducted for studies published between 1990 and December 2015 providing primary data from patients with advanced disease.

RESULTS

Of the 5540 articles surveyed, 19 qualitative and eight quantitative studies met the inclusion criteria. We identified two core structural domains of autonomy: 1) being normal and 2) taking charge. By analyzing these domains, we described eight and 13 elements, respectively, which map the conceptual structure of autonomy within this population of patients.

CONCLUSION

The review shows that maintaining autonomy at the end of life is not only a concern of making choices and decisions about treatment and care but that emphasis should be also put on supporting the patients' engagement in daily activities, in contributing to others, and in active preparation for dying.

Reflections on communication of disease prognosis and life expectancy by patients with colorectal cancer undergoing palliative care: a qualitative study

OBJECTIVES

Patients with colorectal cancer undergoing palliative treatment receive extensive treatment-related information throughout their disease trajectory. We aimed to explore the experiences of patients with incurable colorectal cancer while in palliative care and their reflections on the information provided by physicians and nurses. Our main focus was the patients' thoughts about how information about disease status and life expectancy was communicated, from the first time that they were informed about the incurable nature of their disease through to postsurgery palliative treatment.

SETTINGS

Patients with colorectal cancer receiving palliative chemotherapy.

RESEARCH DESIGN

We used a qualitative approach, and the data were analysed by qualitative content analysis.

PARTICIPANTS

20 patients (34-75 years of age) were included in the study; 12 received first-line chemotherapy and 8 received second-line chemotherapy. Eleven patients were treated by oncologists, and nine were treated by junior physicians.

RESULTS

Data-driven empirical analysis identified three themes: (1) inadequate information during the initial phase of the disease trajectory; (2) hope and information further into the disease trajectory and (3) personal, professional and organisational factors that influenced information and communication throughout the disease trajectory.

CONCLUSION

The participants' experience of being told for the first time that they had an incurable disease was perceived as inadequate, while postsurgery palliative chemotherapy, physicians and nurses offered hope. The participants preferred customised information about their treatment and likely future prospects and physicians and nurses who took a holistic and compassionate approach focusing on their lifeworld. To be a sensitive, holistic and compassionate physician or nurse requires knowledge and confidence. To achieve this requires training and guidance at universities and in hospitals.

Palliative Sedation in Terminal Cancer Patients Admitted to Hospice or Home Care Programs: Does the Setting Matter? Results From a National Multicenter Observational Study

CONTEXT

Few studies regarding palliative sedation (PS) have been carried out in home care (HC) setting. A comparison of PS rate and practices between hospice (HS) and HC is also lacking.

OBJECTIVES

Comparing HC and HS settings for PS rate, patient clinical characteristics before and during PS, decision-making process, and clinical aspects of PS.

METHODS

About 38 HC/HS services in Italy participated in a multicenter observational longitudinal study. Consecutive adult cancer patients followed till death during a four-month period and undergoing PS were eligible. Symptom control and level of consciousness were registered every eight hours to death.

RESULTS

About 4276 patients were screened, 2894 followed till death, and 531 (18%) underwent PS. PS rate was 15% in HC and 21% in HS (P < 0.001). Principal refractory symptoms were delirium (54%) and dyspnea (45%), respectively, more common in HC (P < 0.001) and HS (P = 0.03). Informed consent was not obtained in 72% of patients but achieved by 96% of families. Midazolam was the most used drug (94% HS vs. 75% HC; P < 0.001) mainly by continuous infusion (74% HC vs. 89% HS; P < 0.001). PS duration was less than 48 hours in 67% of patients. Hydration during PS was less frequent in HC (27% vs. 49%; P < 0.001). In the eight hours before death, consciousness level was unrousable to mild physical stimulation in 81% and symptom control complete in 89% of cases.

CONCLUSION

Our results show feasibility of PS in HC and HS and suggest setting differences in rates, indications, and practice of PS, possibly related to patients' selection or care organization.

Exploring symptom meaning: perspectives of palliative care physicians

CONTEXT

Understanding patients' symptom experiences is essential to providing effective clinical care. The discussion between patients and physicians of symptom meaning and its significance, however, is ill understood.

OBJECTIVES

To investigate palliative care physicians' understanding of symptom meaning, and their experiences of and attitudes towards the discussion of symptom meaning with patients.

METHODS

Semi-structured interviews were conducted (N = 17) across Sydney, Australia. Transcripts were analysed using framework analysis.

RESULTS

Six key themes were identified: (1) definitions of symptom meaning (causal meanings, functional impact, existential impact, and cascade of meanings); (2) meanings are personal (demographic, culture, spiritual, and family differences); (3) eliciting meanings requires subtlety and trust (following the patient's cues); discussing meaning can be (4) hard (for the patient and health professional); (5) therapeutic (assuaging fears, feeling listened to and valued, increased sense of control, and reduced symptom distress); and (6) enhances clinicians' practice and work satisfaction (provision of more tailored care, reassurance through the provision of information, and strengthening of doctor-patient relationship).

CONCLUSIONS

Exploring symptom meaning can serve to provide information, alleviate anxiety, and facilitate individualised care, but only when patients present cues or are open to discuss symptom-related concerns. However, various barriers hinder such dialogue in consultations. Greater awareness of symptom meaning and its influence may facilitate physicians exploring symptom meaning more with patients in the future.

Palliative care physicians' experiences of end-of-life communication: A focus group study

The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.

[The acceptability of the intervention Revie ⊕ : the nurses’ perceptions and experiences]

Persons with advanced cancer experience high levels of existential distress due to being confronted with their mortality, which leads to feelings of lack of sense, or discouragement. It is important to develop interventions to relieve existential distress to promote the dignity of persons with advanced cancer in order to help them live this difficult experience in the best possible way. A new intervention, called Revie ⊕ and conducted by nurses, was developed. A feasibility study was conducted with 41 patients with advanced cancer in the ambulatory and hospital sector of a university hospital in Switzerland to determine the acceptability of Revie ⊕. The purpose of this article is to present the intervention’s acceptability from the perspective of the nurses. Nurses conducting the intervention were asked to complete a questionnaire, maintain personal notes, and to participate in one focus group. Descriptive statistics were used to analyze the questionnaire. Thematic analysis was applied to analyze the nurses’ personal notes and focus group data. Results indicate that nurses consider Revie ⊕ to be a beneficial intervention for the patients and also for their professional posture. As a consequence, the nurses wish for its implementation into practice. Recommendations are proposed to promote further implementation.

Revie ⊕: the influence of a life review intervention including a positive, patient-centered approach towards enhancing the personal dignity of patients with advanced cancer-a study protocol for a feasibility study using a mixed method investigation

BACKGROUND

It is generally recognized that existential concerns must be addressed to promote the dignity of patients with advanced cancer. A number of interventions have been developed in this regard, such as dignity therapy and other life review interventions (LRI). However, so far, none have focused on a positive approach or evaluated its effects on dignity and personal growth. This study aims to explore the feasibility of Revie ⊕, a life review intervention comprising a positive, patient-centered approach, and to determine potential changes of patients' sense of dignity, posttraumatic growth, and satisfaction with life.

METHODS

A mixed method study will be performed, which includes specialized nurses and 40 patients with advanced cancer in an ambulatory and in-patient setting of a Swiss university hospital. Quantitative methods involve a single group, pre- and post-intervention, and outcome measurements include the Patient Dignity Inventory, the Posttraumatic Growth Inventory, and the Satisfaction with Life Scale. Feasibility data relating to process, resource, and scientific elements of the trial will also be collected. A semi-directed interview will be used to collect qualitative data about the process and the participants' experiences of the intervention. In this way, enhanced quantitative-qualitative evidence can be drawn from outcome measures as well as individual, contextualized personal views, to help inform researchers about the plausibility of this complex intervention before testing its effectiveness in a subsequent full trial.

DISCUSSION

Patient dignity is a goal of quality end-of-life care. To our knowledge, this is the first trial to evaluate the role of a life review intervention that is focused on personal growth and on changes relating to the experience of having cancer. This study will evaluate the feasibility of a novel intervention, Revie ⊕, which we hope will contribute to promote the dignity, personal growth, and overall life satisfaction of patients with advanced cancer.

TRIAL REGISTRATION

ISRCTN, ISRCTN12497093.

Typology of end-of-life priorities in Saudi females: averaging analysis and Q-methodology

BACKGROUND

Understanding culture-and sex-related end-of-life preferences is essential to provide quality end-of-life care. We have previously explored end-of-life choices in Saudi males and found important culture-related differences and that Q-methodology is useful in identifying intraculture, opinion-based groups. Here, we explore Saudi females' end-of-life choices.

METHODS

A volunteer sample of 68 females rank-ordered 47 opinion statements on end-of-life issues into a nine-category symmetrical distribution. The ranking scores of the statements were analyzed by averaging analysis and Q-methodology.

RESULTS

The mean age of the females in the sample was 30.3 years (range, 19-55 years). Among them, 51% reported average religiosity, 78% reported very good health, 79% reported very good life quality, and 100% reported high-school education or more. The extreme five overall priorities were to be able to say the statement of faith, be at peace with God, die without having the body exposed, maintain dignity, and resolve all conflicts. The extreme five overall dis-priorities were to die in the hospital, die well dressed, be informed about impending death by family/friends rather than doctor, die at peak of life, and not know if one has a fatal illness. Q-methodology identified five opinion-based groups with qualitatively different characteristics: "physical and emotional privacy concerned, family caring" (younger, lower religiosity), "whole person" (higher religiosity), "pain and informational privacy concerned" (lower life quality), "decisional privacy concerned" (older, higher life quality), and "life quantity concerned, family dependent" (high life quality, low life satisfaction). Out of the extreme 14 priorities/dis-priorities for each group, 21%-50% were not represented among the extreme 20 priorities/dis-priorities for the entire sample.

CONCLUSION

Consistent with the previously reported findings in Saudi males, transcendence and dying in the hospital were the extreme end-of-life priority and dis-priority, respectively, in Saudi females. Body modesty was a major overall concern; however, concerns about pain, various types of privacy, and life quantity were variably emphasized by the five opinion-based groups but masked by averaging analysis.

Exploring end of life priorities in Saudi males: usefulness of Q-methodology

Background

Quality end-of-life care depends on understanding patients’ end-of-life choices. Individuals and cultures may hold end-of-life priorities at different hierarchy. Forced ranking rather than independent rating, and by-person factor analysis rather than averaging may reveal otherwise masked typologies.

Methods

We explored Saudi males’ forced-ranked, end-of-life priorities and dis-priorities. Respondents (n = 120) rank-ordered 47 opinion statements on end-of-life care following a 9-category symmetrical distribution. Statements’ scores were analyzed by averaging analysis and factor analysis (Q-methodology).

Results

Respondents’ mean age was 32.1 years (range, 18–65); 52 % reported average religiosity, 88 and 83 % ≥ very good health and life-quality, respectively, and 100 % ≥ high school education. Averaging analysis revealed that the extreme five end-of-life priorities were to, be at peace with God, be able to say the statement of faith, maintain dignity, resolve conflicts, and have religious death rituals respected, respectively. The extreme five dis-priorities were to, die in the hospital, not receive intensive care if in coma, die at peak of life, be informed about impending death by family/friends rather than doctor, and keep medical status confidential from family/friends, respectively. Q-methodology classified 67 % of respondents into five highly transcendent opinion types. Type-I (rituals-averse, family-caring, monitoring-coping, life-quality-concerned) and Type-V (rituals-apt, family-centered, neutral-coping, life-quantity-concerned) reported the lowest and highest religiosity, respectively. Type-II (rituals-apt, family-dependent, monitoring-coping, life-quantity-concerned) and Type-III (rituals-silent, self/family-neutral, avoidance-coping, life-quality & quantity-concerned) reported the best and worst life-quality, respectively. Type-I respondents were the oldest with the lowest general health, in contrast to Type-IV (rituals-apt, self-centered, monitoring-coping, life-quality/quantity-neutral). Of the extreme 14 priorities/dis-priorities for the five types, 29, 14, 14, 50, and 36 %, respectively, were not among the extreme 20 priorities/dis-priorities identified by averaging analysis for the entire cohort.

Conclusions

1) Transcendence was the extreme end-of-life priority, and dying in the hospital was the extreme dis-priority. 2) Quality of life was conceptualized differently with less emphasize on its physiological aspects. 3) Disclosure of terminal illness to family/close friends was preferred as long it is through the patient. 4) Q-methodology identified five types of constellations of end-of-life priorities and dis-priorities that may be related to respondents’ demographics and are partially masked by averaging analysis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0064-5) contains supplementary material, which is available to authorized users.

Advance care planning for cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers

BACKGROUND

Patients with advanced cancer may benefit from end of life (EOL) planning, but there is evidence that their willingness and desire to engage in advance care planning (ACP) varies. The reasons for this remain poorly understood. Previous reviews on ACP most commonly report outcome measures related to medical interventions and type of care. Synthesis of the literature, which aims to illuminate the salient characteristics of ACP and investigates the psychological and social features of preparation for the EOL, is required.

METHODS

We searched Medline, EMBASE, PsychINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for studies on perceptions or experiences regarding ACP of adults with cancer, family, friends, or professionals caring for this group. Databases were searched from earliest records to 19 November 2014. A thematic analysis of the literature generated conceptual themes.

RESULTS

Of the 2483 studies identified, 40 were eligible for inclusion. Studies addressed the relational nature of ACP, fear surrounding ACP, the conceptual complexity of autonomy, and the influence of institutional culture and previous healthcare experiences on ACP.

CONCLUSIONS

The complex social and emotional environments within which EOL planning is initiated and actioned are not sufficiently embedded within standardized ACP. The notion that ACP is concerned principally with the 'right' to self-determination through control over treatment choices at the EOL may misrepresent the way that ACP actually occurs in cancer care and ultimately conflict with the deeper concerns and needs of patients, who experience ACP as relational, emotional, and social.

Patients' preferences in palliative care: A systematic mixed studies review

BACKGROUND

It is necessary to develop palliative care to meet existing and future needs of patients and their families. It is important to include knowledge of patient preferences when developing high-quality palliative care services. Previous reviews have focused on patient preferences with regard to specific components of palliative care. There is a need to review research on patient's combined preferences for all elements that constitute palliative care.

AIM

The aim of this study is to identify preferences for palliative care among patients in the palliative phase of their illness, by synthesizing existing research.

DATA SOURCES

Studies were retrieved by searching databases - the Cochrane Library, Medline, CINAHL, PsycINFO, Scopus and Sociological Abstracts - from 1946 to 2014, and by hand searching references in the studies included.

DESIGN

A systematic mixed studies review was conducted. Two reviewers independently selected studies for inclusion and extracted data according to the eligibility criteria. Data were synthesized using integrative thematic analysis.

RESULTS

The 13 qualitative and 10 quantitative studies identified included participants with different illnesses in various settings. Four themes emerged representing patient preferences for care. The theme 'Living a meaningful life' illustrated what patients strived for. The opportunity to focus on living required the presence of 'Responsive healthcare personnel', a 'Responsive care environment' and 'Responsiveness in the organization of palliative care'.

CONCLUSION

The four themes may be useful for guiding clinical practice and measurements of quality, with the overall goal of meeting future needs and improving quality in palliative care services to suit patients' preferences.

Older people living alone at home with terminal cancer

This study describes the lived experiences of older people coping with terminal cancer and living alone, focusing on how they face challenges of the biographical life changes from their disease progression. Face-to-face semi-structured interviews were conducted in two phases with palliative care clients of a community-based service in Western Australia (2009-2011): Brief interviews with 43 cancer patients who live alone and then in-depth interviews with 8 of them. Using biographical disruption as the analytical framework for interpreting the qualitative data, four main themes emerged: Biographical disruption: adjusting to change; Biographical continuity: preserving normality; Biographical reconstruction: redefining normality; and Biographical closure: facing the end. Biographical disruption was a suitable framework for analysis, permitting identification of the biographical disruptions of the individual's world and the reframing that is undertaken by the individual to maintain autonomy and independence while acknowledging and accepting their closeness to death. Understanding the factors associated with the individual's need to maintain their own identity will enable nurses working with this population to tailor support plans that meet the individuals' needs while maintaining or restoring the person's sense of self. Interventions that directly address end-of-life suffering and bolster sense of dignity and personhood need to be considered.

Impact of specialist home-based palliative care services in a tertiary oncology set up: a prospective non-randomized observational study

BACKGROUND

Home-based specialist palliative care services are developed to meet the needs of the patients in advanced stage of cancer at home with physical symptoms and distress. Specialist home care services are intended to improve symptom control and quality of life, enable patients to stay at home, and avoid unnecessary hospital admission.

MATERIALS AND METHODS

Total 690 new cases registered under home-based palliative care service in the year 2012 were prospectively studied to assess the impact of specialist home-based services using Edmonton symptom assessment scale (ESAS) and other parameters.

RESULTS

Out of the 690 registered cases, 506 patients received home-based palliative care. 50.98% patients were cared for at home, 28.85% patients needed hospice referral and 20.15% patients needed brief period of hospitalization. All patients receiving specialist home care had good relief of physical symptoms (P < 0.005). 83.2% patients received out of hours care (OOH) through liaising with local general practitioners; 42.68% received home based bereavement care and 91.66% had good bereavement outcomes.

CONCLUSION

Specialist home-based palliative care improved symptom control, health-related communication and psychosocial support. It promoted increased number of home-based death, appropriate and early hospice referral, and averted needless hospitalization. It improved bereavement outcomes, and caregiver satisfaction.

Place of care: from referral to specialist palliative care until death

BACKGROUND

While there are many poorly standardised studies focusing on place of death, there are limited data on place(s) of care during the final stages of disease.

AIM

This study aims to identify where patients are cared for in the interval from referral to specialist palliative care until death.

METHODS

All patients who died while under the care of a specialist palliative care service over a 6-month period were considered.

RESULTS

Of the 507 patients included, 255 (50.3%) were men and 428 (84.4%) had a malignant diagnosis. The mean referral-to-death interval was 70 days (SD 113, Range 1-838). The majority (n=281, 55.4%) received care in a single care setting-hospital (28.4%), home (21.5%), nursing home/community hospital (4.1%), hospice (1.4%)-and had a shorter mean referral-to-death interval. Most patients with more than one care setting spent three-quarters of their time in their normal place of residence. A total of 199 (39.3%) died in hospital, 131 (25.8%) in hospice, 131 (25.8%) at home (25.8%) and 46 (9.1%) in a nursing home/community hospital. Patients referred by a general practitioner (n=80 patients, 15.8%) were more likely to be cared for at home (p<0.001), and die at home (p<0.001).

CONCLUSIONS

A significant number of patients received specialist palliative care across multiple care settings. Late referral is associated with a single domain of care. General practitioner involvement supports patient care and death at home. Place of care and ease of transfer between care settings may be better indicators of the quality of care we provide.

Preference of the place of death among people of pune

Aim:

Provision of end-of-life care requires that we have adequate information about the preferred place of death in the population. Since no such study is reported in India, this study was taken up in and around Pune, a large cosmopolitan city.

Setting and Design:

A questionnaire was designed in three parts and distributed among the people above the age of 18 in and around Pune.

Materials and Methods:

The questionnaire had three parts the first being a consent form, followed by one for collection of personal information and lastly questions specific to the subject matter. Filled forms were screened for inconsistencies, gaps of information and errors.

Results:

The population survey was mixed, both urban and rural, men and women, educated and uneducated, young and old. Despite this heterogeneity, the results were consistent to the point that most of the people surveyed preferred home as the place of death. This preference cuts across all barriers, the only difference being that women had a stronger preference for home death compared to men.

Conclusions:

Helping people to die at their preferred place is a part of end-of-life care. Majority of people surveyed by us, prefer to die at home, where they are relatively more comfortable. Public and governmental policies should be directed toward facilitating home deaths.

Belgian general practitioners' perspectives on the use of palliative sedation in end-of-life home care: a qualitative study

CONTEXT

Palliative sedation (PS) is a far-reaching palliative measure with a life-shortening potential. Guidelines provide only for a restricted use of PS and as a last resort.

OBJECTIVES

To explore PS practice in end-of-life (EoL) home care.

METHODS

This was a qualitative analysis of semi-structured interviews with 52 general practitioners (GPs) of Flanders, Belgium.

RESULTS

Apart from GPs who adhere to the existing prerequisites for PS, opinions diverge among GPs on the indication area for PS and on possible life-shortening intentions. The key to GPs' broadened view on "which suffering merits PS" is the fragile context of EoL home care, and the key to GPs' possible life-shortening intentions is their need to facilitate the dying process, when trying or lengthy. When honoring a terminally ill patient's request for euthanasia, several GPs prefer slow euthanasia using PS to a lethal injection.

CONCLUSION

PS home practice deviates from the PS guidelines' recommendations. In addition to the GPs' shortage of knowledge, the guidelines' recommendations do not always meet the particular needs of EoL home care. If one consideration of EoL home care is to respect a patient's wish to die at home, then the pre-emptive use of PS to avoid a futile transfer to the hospital in the case of an undesirable turn of events deserves more attention in the PS debate.

Decisional control preferences, disclosure of information preferences, and satisfaction among Hispanic patients with advanced cancer

CONTEXT

Studies to determine the decisional control preferences (DCPs) in Hispanic patients receiving palliative care are limited.

OBJECTIVES

The aims of this study were to describe DCPs, disclosure of information, and satisfaction with decision making among Hispanics and to determine the degree of concordance between patients' DCPs and their self-reported decisions.

METHODS

We surveyed 387 cancer patients referred to outpatient palliative care clinics in Argentina, Chile, Guatemala, and the U.S. DCPs were measured with the Control Preference Scale, disclosure preferences with the Disclosure of Information Preferences questionnaire, and satisfaction with care with the Satisfaction with Decision Scale.

RESULTS

In this study, 182 patients (47.6%) preferred shared decisional control, 119 (31.2%) preferred active decisional control, and 81 (21.2%) preferred a passive approach. Concerning their diagnosis and prognosis, 345 (92%) patients wanted to know their diagnosis, and 355 (94%) wanted to know their prognosis. Three hundred thirty-seven (87%) patients were satisfied with the decision-making process. DCPs were concordant with the self-reported decision-making process in 264 (69%) patients (weighted kappa = 0.55). Patients' greater satisfaction with the decision-making process was correlated with older age (P ≤ 0.001) and with a preference for enhanced diagnostic disclosure (P ≤ 0.024). Satisfaction did not correlate with concordance in the decision-making process.

CONCLUSION

The vast majority preferred a shared or active decision-making process and wanted information about their diagnosis and prognosis. Older patients and those who wanted to know their diagnosis seemed to be more satisfied with the way treatment decisions were made.

Religious faith in coping with terminal cancer: what is the nursing experience?

This qualitative study describes nurses' reports on the role played by religious faith in the care of patients with terminal cancer. Using Gadamer's philosophical hermeneutics and C. Roy's adaptation model as a base, in-depth interviews were carried out with 23 nurses who had cared for patients with terminal cancer for at least 6 months. Three main themes emerged when a Gadamerian-based hermeneutic research method was applied: faith facilitates the coping process in cases of terminal cancer, faith hinders the coping process in cases of terminal cancer and terminal illness impacts faith. The lack of univocal results indicates that the role of faith in coping with death is essentially practical, individualised and changeable. The nurse-patient relationship can help to determine the spiritual needs of cancer patients at the end of life. This source of knowledge held by the nurse, together with the rest of the multidisciplinary team, can help to improve end-of-life care.