Initiating end-of-life care pathways: a discussion paper

End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model

BACKGROUND

Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research.

PURPOSE

To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model.

METHOD

Walker and Avant's approach to concept analysis.

FINDINGS

End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences).

DISCUSSION

Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.

Final-year nursing undergraduates' understandings of palliative care: a qualitative study in Wales, UK

BACKGROUND

With worldwide population ageing and the increasing prevalence of chronic conditions, government policies promoting palliative care, and evidence of disparate or even blurred conceptions of palliative care, it is important for educators and practitioners who support undergraduate nurses to establish how these students conceptualise palliative care. Today's students are tomorrow's nurses, and their understanding will shape the ways in which palliative care is integrated into their professional practice.

AIM

The aim of this work was to explore nursing undergraduates' understandings of palliative care.

METHODS

As part of a larger qualitative study of palliative care for people with advanced dementia, 11 final-year adult-field nursing undergraduates' understandings of palliative care were explored through in-depth individual interviews. The data was subject to thematic content analysis.

FINDINGS

The analysis revealed that the participants were cognisant of the broad scope of palliative care. Moreover, they valued and appreciated compassionate comfort care and emotional support. However, their understanding was rather superficial and focused on the imminently dying phase.

CONCLUSION

The findings are positive as they indicate that the participants appreciated and valued compassionate person- and family-centred care. However, they also illuminate where undergraduate nurse education could be further enhanced.

Tensions and ambiguities: A qualitative study of final year adult field nursing students' experiences of caring for people affected by advanced dementia in Wales, UK

BACKGROUND

Rising dementia prevalence means that general nurses globally will encounter more people affected by advanced dementia. Advanced dementia care is profoundly complex yet there is a paucity of research exploring how general nursing students experience and thus learn to care for those affected.

OBJECTIVES

To explore final year nursing students' (adult field) experiences of caring for people affected by advanced dementia.

DESIGN

A qualitative design was adopted.

SETTING

The setting was Wales, UK.

PARTICIPANTS

Eleven final year nursing undergraduates (adult field).

METHOD

Data were collected using digitally recorded one-to-one in-depth interviews in 2013 and analysed using thematic analysis.

RESULTS

Participants' experiences fell within three main themes: they can be quite challenging; a lot of dementia patients are seen as hazards and it's not all about doing stuff. Participants aspired to person-centred care. However, they felt insufficiently prepared for what they believed was knowledgeable work requiring interpersonal competence and confidence. Participants appreciated that many practitioners, their clinical educators, were insufficiently prepared for advanced dementia care.

CONCLUSIONS

The study provided further evidence of the complexity of caring for those with advanced dementia and associated theory, practice and policy gaps. There are important implications for education in terms of curriculum development and learning from and in practice.

“It's been quite a challenge”: Redesigning end-of-life care in acute hospitals

Objective:

This paper reports the findings of an interview-based study undertaken to investigate the introduction of end-of-life (EoL) care pathways in three acute trusts, as part of a larger project examining service redesign. The aim was to examine the barriers to and facilitators of change.

Method:

Twenty-one in-depth qualitative interviews were conducted with staff working in three National Health Service (NHS) acute hospital trusts. These staff members were involved in end-of-life care, and their accounts were analyzed to identify the key issues when introducing service changes in these settings.

Results:

Thematic analysis revealed five major themes—two of which, leadership and facilitation, and education and training, indicate what needs to be in place if end-of-life care pathways are to be adopted by staff. However, the remaining three themes of difficult conversations, diagnosing dying, and communication across boundaries highlight particular areas of practice and organization that need to be addressed before end-of-life care in hospitals can be improved.

Significance of results:

Organization of end-of-life care in acute hospitals is challenging, and care pathways provide a degree of guidance as to how services can be delivered. However, even when there is effective leadership at all levels of an organization and an extensive program of education for all staff support the use of care pathways, significant barriers to their introduction remain. These include staff anxieties concerning diagnosing dying and discussing dying and end-of-life care planning with patients and their families. It is hoped these findings can inform the development of the proposed new care plans which are set to replace end of life care pathways in England.

The media critique of the Liverpool Care Pathway: some implications for nursing education

End-of-life care pathways are championed around the globe as tools that might be used to enhance the quality of care at the very end of a person's life. This paper examines recent negative media discourse in the UK about the Liverpool Care Pathway for the Dying Patient (LCP). This media coverage may have had damaging effects, but it has also served to highlight inappropriate and even suboptimal end-of-life care. While recognising the pervading influence of organisational structures and cultures, some implications for initial and ongoing education of nurses are identified.