A systematic review of informal caregivers' needs in providing home-based end-of-life care to people with cancer

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Family Caregivers

Family and friend caregivers play critical roles in ensuring that persons with serious illness receive high-quality care, and their responsibilities often increase as patients transition from receiving solely curative-focused care to primarily palliative-focused care. Integrating family caregivers into the health care team and supporting them in their role has significant benefits for family caregivers, patients, health care systems, communities, and society. Palliative care clinicians across all disciplines are uniquely suited to provide necessary training and support to family caregivers as they navigate the demands of their role. Here, we contend that providing comprehensive palliative care includes addressing the needs of family caregivers and provide ten tips and practical guidance to assist palliative care clinicians to support family caregivers. Engaging family caregivers as partners in care will ultimately allow palliative care clinicians to deliver the highest quality patient care and ensure the best possible outcomes for families facing serious illnesses.

Relative's suggestions for improvements in support from health professionals before and after a patient's death in general palliative care at home: A qualitative register study

INTRODUCTION

The efforts of relatives in providing palliative care (PC) at home are important. Relatives take great responsibility, face many challenges and are at increased risk of poor physical and mental health. Support for these relatives is important, but they often do not receive the support they need. When PC is provided at home, the support for relatives before and after a patient's death must be improved. This study aimed to describe relatives' suggestions to improve the support from health professionals (HPs) before and after a patient's death in general PC at home.

METHODS

This study had a qualitative descriptive design based on the data from open-ended questions in a survey collected from the Swedish Register of Palliative Care. The respondents were adult relatives involved in general PC at home across Sweden. The textual data were analysed using thematic analysis.

RESULTS

The analysis identified four themes: (1) seeking increased access to HPs, (2) needing enhanced information, (3) desiring improved communication and (4) requesting individual support.

CONCLUSIONS

It is important to understand and address how the support to relatives may be improved to reduce the unmet needs of relatives. The findings of this study offer some concrete suggestions for improvement on ways to support relatives. Further research should focus on tailored support interventions so that HPs can provide optimal support for relatives before and after a patient's death when PC is provided at home.

Caregivers' demands: caring atmosphere expected by cancer patients' caregivers-a qualitative content analysis

PURPOSE

Family caregivers play a critical role in providing care for patients with cancer. However, the quality of their caregiving can be greatly impacted if the demands and expectations they experience are not identified. Therefore, this study aimed to explore the demands and perceived expectations of caregivers while caring for cancer patients.

METHODS

This qualitative study was conducted from June 2022 to September 2023. Face-to-face and in-depth semi-structured interviews were conducted to collect the experiences of 19 Iranian family caregivers of patients with cancer. Purposive sampling was used to select the participants. The interviews were analyzed using conventional content analysis and the rigor of the study was ensured by employing Lincoln and Guba's criteria.

RESULTS

Three main themes and six subthemes were identified through data analysis. The themes that emerged from the caregivers' experiences included the following: (1) ambiguity in the healthcare system, (2) need for empathetic communication, and (3) forgotten caregivers in the healthcare system.

CONCLUSION

Caregivers often feel overlooked, resulting in unfulfilled needs and expectations. It is imperative to explore potential solutions that provide caregivers information, empathetic communication, and support. Nurses, as key members of the healthcare team, should play a significant role in addressing this problem.

Dying at home: What is needed? Findings from a nationwide retrospective cross-sectional online survey of bereaved people in Germany

OBJECTIVES

According to the "Last Year of Life in Cologne" study, 68% of patients with a serious and terminal illness wanted to die at home, but 42% died in hospital. Only 1 in 5 died at home. Most people want to spend their last days and hours at home, but the reality is that this is not always possible. Recommendations are needed on how best to support families to enable people to die at home - if this is their preferred place of death. Our aim was to identify the factors that make it possible for people to die at home and to analyze factors of dying at home.

METHODS

Germany-wide quantitative cross-sectional online survey of bereaved adult relatives.

RESULTS

The needs of 320 relatives of patients who wished to die at home were explored. Of these, 198 patients died at home and 122 did not. In the last 3 months of life, caregivers needed support in managing out-of-hours care (p < 0.001), financing (p = 0.012), preparing and organizing home care (both p < 0.001), communicating with the patient and medical staff (p = 0.012 and p = 0.009, respectively), and pain management (p < 0.001). Relatives whose next of kin did not die at home had higher needs, suggesting that these factors are key to home care of the dying.

SIGNIFICANCE OF RESULTS

The process of dying at home begins long before the actual dying phase. To minimize caregiver burden and improve symptom management, advanced home care plans are needed, with ongoing reassessment of family preferences and abilities.

A study protocol for e-PainSupport: The use of a digital application for reporting pain and pain management in home hospice

High pain intensity is commonly experienced by patients with serious advanced illness. Impediments to improving pain intensity in home hospice include poor adherence to a pain management regimen due to caregivers' lack of knowledge and self-efficacy (confidence) in administering analgesics. e-PainSupport is a self-administered, digital application directly linked to patients' medical records. It has three elements: Education Module, Patient Pain Record, and the Pain Summary for Nurses. This study will test the effects of e-PainSupport on pain intensity when used by patients, caregivers, and nurses. The study's specific aims are as follows: Aim 1, compare the effects of e-PainSupport to a standard care condition, controlling for covariates (role [patient or caregiver], age, sex, ethnicity, education, and patient's diagnosis), on clinical improvement in pain intensity (primary outcome) and significant improvement on a pain intensity scale (secondary outcome); Aim 2, examine the mediating effects of patient and caregiver knowledge, self-efficacy, and adherence on change in pain intensity during 2 weeks, controlling for covariates and treatment condition; and Aim 3, identify nurses' perceptions of the use of e-PainSupport, including facilitators for and barriers to integration into agency workflow and benefits for patients. Participants (132 triads of patients, caregivers, and hospice nurses) will be recruited from Midwest hospice agencies. Patient and caregiver outcomes will be assessed at baseline and 2 weeks later. Data will be analyzed with multilevel modeling. Post-intervention, semi-structured interviews with nurses in the e-PainSupport condition will be analyzed using qualitative content analysis to identify perceived practice changes. e-PainSupport has the potential to facilitate nurse-patient communication and improve hospice patient pain management.

Caregiver strain among patients of palliative care in Sri Lanka: validation of modified caregiver strain index - Sinhala version

BACKGROUND

Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka.

METHODS

After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett's test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule).

RESULTS

The total MCSI score ranged 0 to 26. The overall Cronbach's alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett's test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor.

CONCLUSIONS

The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

Healthcare utilization among informal caregivers of older adults in the Ashanti region of Ghana: a study based on the health belief model

BACKGROUND

Existing global evidence suggests that informal caregivers prioritize the health (care) of their care recipients (older adults) over their own health (care) resulting in sub-optimal health outcomes among this population group. However, data on what factors are associated with healthcare utilization among informal caregivers of older adults are not known in a sub-Saharan African context. Guided by the Health Belief Model (HBM), the principal objective of this study was to examine the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

METHODS

Data were extracted from a large cross-sectional study of informal caregiving, health, and healthcare survey among caregivers of older adults aged 50 years or above (N = 1,853; mean age of caregivers = 39.15 years; and mean age of care recipients = 75.08 years) in the Ashanti Region of Ghana. Poisson regression models were used to estimate the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults. Statistical significance of the test was set at a probability level of 0.05 or less.

RESULTS

The results showed that 72.9% (n = 1351) of the participants were females, 56.7% (n = 1051) were urban informal caregivers and 28.6% (n = 530)  had no formal education. The results further showed that 49.4% (n = 916) of the participants utilized healthcare for their health problems at least once in the past year before the survey. The final analysis showed a positive and statistically significant association between perceived susceptibility to a health problem (β = 0.054, IRR = 1.056, 95% CI = [1.041-1.071]), cues to action (β = 0.076, IRR = 1.079, 95% CI = [1.044-1.114]), self-efficacy (β = 0.042, IRR = 1.043, 95% CI = [1.013-1.074]) and healthcare utilization among informal caregivers of older adults. The study further revealed a negative and statistically significant association between perceived severity of a health problem and healthcare utilization (β= - 0.040, IRR = 0.961, 95% CI= [0.947-0.975]) among informal caregivers of older adults. The results again showed that non-enrollment in a health insurance scheme (β= - 0.174, IRR = 0.841, 95% CI= [0.774-0.913]) and being unemployed (β= - 0.088, IRR = 0.916, 95% CI= [0.850-0.986]) were statistically significantly associated with a lower log count of healthcare utilization among informal caregivers of older adults.

CONCLUSION

The findings of this study to a large extent support the dimensions of the HBM in explaining healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana. Although all the dimensions of the HBM were significantly associated with healthcare utilization in Model 1, perceived barriers to care-seeking and perceived benefits of care-seeking were no longer statistically significant after controlling for demographic, socio-economic and health-related variables in the final model. The findings further suggest that the dimensions of the HBM as well as demographic, socio-economic and health-related factors contribute to unequal healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

Support given by health professionals before and after a patient's death to relatives involved in general palliative care at home in Sweden: Findings from the Swedish Register of Palliative Care

OBJECTIVES

General palliative care (PC) is provided more at home, leading to increased involvement of relatives. Although support for relatives is a fundamental component of PC, there are deficiencies in the support provided to relatives when general PC is provided at home. This study aimed to describe the support provided by health professionals before and after a patient's death to relatives involved in general PC at home.

METHODS

A cross-sectional register study was implemented, with data from the Swedish Register of Palliative care. The sample consisted of 160 completed surveys from relatives who had been involved in general PC at home, with 160 related surveys answered by health professionals. Only the questions about support to relatives were used from the surveys.

RESULTS

The findings showed that although many relatives appear to receive support in general PC at home, not all relatives receive optimal support before or after a patient's death. The findings also indicated differences in whether relatives received some support before and after a patient's death depending on the type of relative. There were also differences in responses between health professionals and relatives regarding if relatives received counseling from a doctor about whether the patient was dying.

SIGNIFICANCE OF RESULTS

There is potential for improvements regarding support for relatives, especially after a patient's death, which has been confirmed in previous studies. The differences in whether relatives received support before and after a patient's death depending on the type of relative highlight the need for future research on how to support different types of relatives before and after a patient's death when general PC is provided at home.

Caregiver's quality of life in advanced cancer: validation of the construct in a real-life setting of early palliative care

Introduction

Early palliative care (EPC) improves the quality of life (QoL) of advanced cancer patients and their caregivers. The increasingly widespread use of this care model requires the development of measures supporting its interventions. Although the construct of patient's QoL has been extensively investigated and several QoL measures have been further validated, there is a paucity of data concerning the QoL of the caregiver. In 2018, McDonald and colleagues addressed this issue by interviewing 23 primary caregivers of advanced cancer patients who participated in an EPC randomized clinical trial to understand their perspective on the QoL construct. The Authors identified six major dimensions associated with the construct of caregiver's QoL. The present retrospective study aimed to validate these dimensions on a larger sample and in a real-life EPC setting.

Methods

Previously collected reports from 137 primary caregivers of advanced cancer patients on EPC answering questions about their experience with this care model were qualitatively analyzed through a deductive, thematic approach to identify and confirm the six dimensions constituting the construct of interest based on McDonald's and colleagues' results.

Results

The six dimensions ("living in the patient's world", "burden of illness and caregiving", "assuming the caregiver role", "renegotiating relationships", "confronting mortality", and "maintaining resilience") were consistently found in the reports from primary caregivers in a real-life EPC setting, confirming to be significant themes associated to their QoL.

Conclusion

A definite and recurrent construct of primary caregiver's QoL as described by McDonald and colleagues was also found in a larger sample and in a real-life EPC setting. Thus it may lay the groundwork for the development of a dedicated questionnaire.

Perspectives in preparedness of family caregivers of patients with cancer providing end-of-life care in the home: A narrative review of qualitative studies

BACKGROUND

Many patients with advanced cancer identify home as being their preferred place of death. A critical component in achieving a home death is the support of family members, who often take on responsibilities for which they feel insufficiently prepared with subsequent impacts upon their health and well-being.

OBJECTIVES

This study sought to review existing qualitative literature on family carers' experiences in providing end-of-life care at home for patients with advanced cancer, with an emphasis on exploring factors that influence how prepared they feel for their role.

METHODS

A narrative review was chosen to provide an overview and analysis of qualitative findings. MEDLINE, PubMed, PsychINFO, and EMBASE databases were searched with the following search terms: "Cancer," "Caregiver," "End of Life Care," "Home," and "Qualitative." Inclusion criteria were as follows: English language, empirical studies, adult carers, and articles published between 2011 and 2021. Data were abstracted, and study quality was assessed using the Critical Appraisal Skills Programme checklist for qualitative research.

RESULTS

Fourteen relevant articles were included. Three overarching themes reflecting the factors influencing family preparedness for their role were identified: "motivations for providing care," "interactions with health-care professionals," and "changes during the caring process."

SIGNIFICANCE OF RESULTS

Inadequate preparation of family carers is apparent with regard to their role in providing end-of-life care at home for patients with advanced cancer. There is a need for health-care workers to more effectively identify the information and support needs of families, and utilize evidence-based strategies that have emerged to address these needs.

The experience of informal caregiving within Saudi society: expressed needs and expectations

BACKGROUND

Even though informal caregivers have always been a major element within any society, their contribution to the healthcare system has only recently been recognized. Accordingly, the sustainability of their informal social role is becoming a major concern to policymakers. In Saudi Arabia, recognition of informal caregiving is still limited. This study was carried out to investigate the experience of caregiving in informal settings through identifying the needs of the caregivers along with their expectations of the formal system.

METHODS

A cross-sectional study was conducted to measure the experience of Saudi informal caregivers who were caring for at least one individual with a dependency resulting from either disability, aging, or both. A self-administered questionnaire was designed specifically for this study with 88% reliability. A convenient sample of 300 caregivers was invited electronically through 14 websites supporting families with dependent individuals.

RESULTS

Of the eligible participants (n = 271), about two-thirds were caring for one elderly person or more, while one-third were caring for individual(s) with disabilities. The two groups did not differ in their needs; their greatest perceived needs were necessary equipment for care recipients, free time to socialize, alternative care setting, and proper income. Overall, the needs on the system level were the highest, followed by the needs on the financial level, then on the social level. On the other hand, the caregivers of individuals with disabilities had greater expectations of formal support than caregivers of the elderly. The greatest expectation among the participants was facilitating care recipients' mobility within their communities. Overall, the expectations of information support were the highest followed by the expectations of financial support and then material support.

CONCLUSION

The participants expressed great expectations of formal support along with some unmet needs. Further research is recommended to emphasize the role of primary caregivers along with the nature of the assistance received throughout the caregiving process. The needs of individuals with dependencies along with those of the caregivers must be considered in the planning process of healthcare services. Finally, the expectations of informal caregivers should lead the priorities of the development decisions of long-term care services.

Effects of psychosocial interventions for caregivers of breast cancer patients: A systematic review and meta-analysis

Aim

The aim of this review was to determine whether the caregivers of breast cancer patients who undergo psychosocial interventions report improvements in quality of life (QOL), depression, and anxiety.

Methods

This systematic review was conducted in accordance with the PRISMA guidelines. A systematic search was conducted in the CINAHL, Embase, PsycINFO, PubMed, Web of Science, CNKI and Wanfang databases from inception until March 1, 2022. Randomized controlled trials (RCTs) and quasiexperimental studies involving psychosocial interventions for caregivers of breast cancer patients were included. Cochrane's risk of bias tool and the Joanna Briggs Institute checklist were used to assess the risk of bias.

Results

This systematic review included eight original studies involving 528 caregivers of breast cancer patients. According to the meta-analyses, psychosocial interventions contributed significantly to improvements in QOL (SMD = 1.00, 95% CI [0.47, 1.54], p < 0.01), depression (SMD = -0.72, 95% CI [-1.02, -0.42], p < 0.01) and anxiety (SMD = -0.56, 95% CI [-0.86, -0.27], p < 0.01). Significant differences of psychosocial interventions on the QOL of caregivers were found in face-to-face and mixed-method psychosocial interventions (SMD = 0.97, 95% CI [0.19,1.75], p = 0.02; SMD = 1.45, 95% CI [0.86,2.05], p < 0.01) in the ≥3 months subgroup (SMD = 1.22, 95% CI [0.58,1.86], p < 0.01) but not in the spouses or partners subgroup (SMD = 0.83, 95% CI [-0.10,1.75], p = 0.08).

Conclusions

This systematic review revealed that breast cancer patients' caregivers who undergo psychosocial interventions report improvements in QOL and reduced levels of depression and anxiety. It is worthwhile to use face-to-face methods when psychosocial interventions are conducted for caregivers. Future studies should examine long-term psychosocial interventions for spouses or partners of breast cancer patients. However, because of the limited number of original studies and the low quality of some included studies, the results should be treated cautiously. To increase solid evidence in this field, higher quality, more original studies are needed.

Design suggestions for a persuasive e-coaching application: A study on informal caregivers' needs

Objective

Informal caregivers such as relatives or close friends of patients are essential for caregiving at home. However, caregiving is a complex experience that may affect the caregivers' well-being. Therefore, there is a need to provide support for caregivers, which we address in this article by proposing design suggestions for an e-coaching application. This study identifies the unmet needs of caregivers in Sweden and provides design suggestions for an e-coaching application using the persuasive system design (PSD) model. The PSD model offers a systematic approach to designing IT interventions.

Methods

A qualitative research design was used, and semi-structured interviews were conducted with 13 informal caregivers from different municipalities in Sweden. A thematic analysis was performed to analyze the data. The PSD model was used to map the needs emerging from this analysis to propose design suggestions for an e-coaching application for caregivers.

Results

Six needs were identified, and based on them, we proposed design suggestions for an e-coaching application using the PSD model. These unmet needs are monitoring and guidance, assistance to avail formal care services, access to practical information without being overwhelmed, feeling of community, access to informal support, and grief acceptance. The last two needs could not be mapped using the existing PSD model, resulting in an extended PSD model.

Conclusion

This study revealed the important needs of informal caregivers based on which design suggestions for an e-coaching application were presented. We also proposed an adapted PSD model. This adapted PSD model can be further used for designing digital interventions in caregiving.

The role of community health workers in palliative care in a rural subdistrict in South Africa

BACKGROUND

Effective palliative care is an urgent humanitarian need, particularly in less developed countries, including South Africa (SA). People can be palliated within their communities, motivating the integration of palliative care into primary healthcare systems. While community health workers (CHWs) play a vital role in health coverage at the primary care level, literature on their roles in palliation is limited.

AIM

To explore the roles of CHWs in palliative care delivery in a rural subdistrict in SA.

SETTING

This study was conducted in the George subdistrict of the Western Cape province, SA.

METHODS

A descriptive qualitative study explored the perceptions of a wide range of stakeholders (n = 39) of CHWs' roles in palliative care. Data were collected via semistructured interviews and focus group discussions and analysed thematically.

RESULTS

Patients experienced severe biopsychosocial symptoms and needed home-based palliation. While CHWs identified and referred patients, their main responsibilities were health promotion and disease prevention. Palliation was primarily a registered nurse's function. Community health workers were conflicted by their limited ability to deliver basic palliative care to patients.

CONCLUSION

While there is a definite need for community-based palliative care, the optimal structure of such a service and the roles of CHWs therein are uncertain. Future research should explore the home-based palliation needs of patients in similar contexts and the service design best suited to address these needs within the primary healthcare domain.Contribution: This study illustrates the influence of individual and system-related factors on CHWs' roles in palliative care. It can inform service design to optimise CHWs' contribution to palliation within primary health care.

Home Cancer Care Research: A Bibliometric and Visualization Analysis (1990-2021)

Home cancer care research (HCCR) has accelerated, as considerable attention has been placed on reducing cancer-related health costs and enhancing cancer patients' quality of life. Understanding the current status of HCCR can help guide future research and support informed decision-making about new home cancer care (HCC) programs. However, most current studies mainly detail the research status of certain components, while failing to explore the knowledge domain of this research field as a whole, thereby limiting the overall understanding of home cancer care. We carried out bibliometric and visualization analyses of Scopus-indexed papers related to home cancer care published between 1990-2021, and used VOSviewer scientometric software to investigate the status and provide a structural overview of the knowledge domain of HCCR (social, intellectual, and conceptual structures). Our findings demonstrate that over the last three decades, the research on home cancer care has been increasing, with a constantly expanding stream of new papers built on a solid knowledge base and applied to a wide range of research themes.

Physicians' perceptions of patient participation and the involvement of family caregivers in the palliative care pathway

Introduction

Patient participation is essential for quality palliative care, and physicians play a crucial role in promoting participation. This study explores physicians' perceptions of patients and family caregivers' involvement in the different phases of the palliative pathway and employs a qualitative design with thematic analysis and a hermeneutic approach.

Methods

A purposive sampling included physicians who worked in different phases of the palliative pathway. In‐depth, semi‐structured interviews were conducted with 13 physicians in Norway between May and June 2020.

Results

Three main themes illustrate physicians' perceptions of patients' and family caregivers' involvement: (1) beneficence for the patient and the family caregivers in the early phase, (2) autonomy and shared decision‐making in the middle phase, and (3) family involvement in the terminal phase.

Conclusion

The physicians perceived bereavement conversations as essential, particularly if the pathway had been challenging. They also perceived patient participation and family caregivers' involvement as contextual. The results reveal that participation differs across the different phases of the palliative pathway. This type of knowledge should be included in the education of health‐care professionals. Future research should explore elements vital to successful patient participation and family involvement in the different phases of care.

Patient or Public Contributions

Family caregivers were involved in a previous study through individual interviews. The same interview guide used for the family caregivers was used when interviewing the physicians. The family caregivers' contribution led to nuanced questions in the interviews with the physicians, questions leaning on their stories told.

Characterizing uncertainty in goals-of-care discussions among black and white patients: a qualitative study

BACKGROUND

Uncertainty has been associated with distress and poorer quality of life in patients with advanced cancer. Prior studies have focused on prognostic uncertainty; little is known about other types of uncertainty that patients and family members experience when discussing goals of care. Understanding the types of uncertainty expressed and differences between Black and White patients can inform the development of uncertainty management interventions.

METHODS

This study sought to characterize the types of uncertainty expressed by Black and White patients and family members within the context of information needs during inpatient goals-of-care discussions. We performed a secondary analysis of transcripts from 62 recorded goals-of-care discussions that occurred between 2012 and 2014 at an urban, academic medical center in the United States. We applied an adapted taxonomy of uncertainty to data coded as describing information needs and used an inductive qualitative analysis method to analyze the discussions. We report the types of uncertainty expressed in these discussions.

RESULTS

Fifty discussions included patient or family expressions of information needs. Of these, 40 discussions (n=16 Black and n=24 White) included statements of uncertainty. Black and White patients and families most frequently expressed uncertainty related to processes and structures of care (system-centered uncertainty) and to treatment (scientific uncertainty). Statements of prognostic uncertainty focused on quantitative information among Whites and on qualitative information and expectations for the future among Blacks.

CONCLUSIONS

Black and White patients and families frequently expressed system-centered uncertainty, suggesting this may be an important target for intervention. Addressing other sources of uncertainty, such as prognostic uncertainty, may need more tailored approaches.

Understanding the Experiences of end of Life Care for Patients with Mesothelioma from the Perspective of Bereaved Family Caregivers in the UK: A Qualitative Analysis

OBJECTIVES

Mesothelioma is a rare, progressive cancer with a short trajectory from diagnosis to the end of life. This study explores the experiences of palliative and end of life care for patients with mesothelioma from the perspective of bereaved family caregivers.

METHODS

A qualitative, descriptive approach was adopted comprising face-to-face, semi-structured interviews with bereaved caregivers of patients with mesothelioma in the UK. An inductive, thematic analysis was conducted using the 'Framework' approach.

RESULTS

Nine bereaved caregivers participated. Four themes emerged: understanding what lies ahead; carer support; care co-ordination; managing after death: practicalities, inquests and abandonment. Caregivers need to understand what lies ahead in order to emotionally and practically prepare themselves for supporting the patient at the end of life. Information and support needs of caregivers were often distinct from those of patients, including the importance of information about the coroner's involvement. The importance of care co-ordination was emphasised, with caregivers valuing on-going relationships and a named individual taking responsibility for co-ordinating the patients care. Feelings of abandonment arose when there was no contact with healthcare professionals following the death of the patient.

CONCLUSIONS

Greater opportunity for open, one-to-one communication between family caregivers and healthcare professionals is vital to enable the caregiver to prepare for what lies ahead at the end of life and prevent feelings of abandonment after the death of the patient. Improved care co-ordination and partnership working are essential for supporting both patient and caregiver at the end of life.

Support Needs for Bhutanese Family Members Taking Care of Loved Ones Diagnosed with Advanced Illness

Background: Palliative care aims to improve the quality of life of patients diagnosed with an advanced illness and their families. Family members, who often play a central role caring for their very ill loved ones, have significant support needs. In Bhutan, where palliative care is an emerging concept, the needs of family members have not been assessed thus far. Objective: This study explored the support needs of Bhutanese family members caring for their loved ones diagnosed with advanced illness. Design: This is a cross-sectional descriptive study. Setting/Subjects: Study sites included the national referral hospital, the two regional referral hospitals, four district hospitals and Basic Health Units (Grade I and II), spread across Bhutan. Participants were recruited through purposeful and snowball sampling strategies. Data were collected from May to August 2019. The Carer Support Needs Assessment Tools (CSNAT) was used. Results: Despite unforeseen challenges, 46 family members out of 60 identified (77%) participated in the survey. Twenty-three (50%) cared for relatives with advanced cancer and the remainder for loved ones with non-malignant conditions. This study found high support needs among both groups. The priority needs included understanding their relative's illness, managing symptoms, providing personal care, financial aspects, dealing with their own feelings and emotions and knowing what to expect in the future. Conclusion: This study will help inform the World Health Organization recommended public health approach to palliative care modified to the Bhutanese context for enabling a cost-effective intervention to improve the quality of lives of patients and families.

Palliative and End-of-Life Care Service Models: To What Extent Are Consumer Perspectives Considered?

This article presents evidence found in a search of national and international literature for patient preferences concerning settings in which to receive palliative care and the appropriateness of different models of palliative care. The purpose was to inform end-of-life care policy and service development of the Western Australian Department of Health through a rapid review of the literature. It was found that consumer experience of palliative care is investigated poorly, and consumer contribution to service and policy design is limited and selective. Most patients experience a mix of settings during their illness, and evidence found by the review has more to do with qualities and values that will contribute to good end-of-life care in any location. Models of care do not make systematic use of the consumer data that are available to them, although an increasingly common theme is the need for integration of the various sources of care supporting dying people. It is equally clear that most integration models limit their attention to end-of-life care provided by health services. Transitions between settings merit further attention. We argue that models of care should take account of consumer experience not by incorporating generalised evidence but by co-creating services with local communities using a public health approach.

Process, content, and experiences of delivering the Carer Support Needs Assessment Tool Intervention (CSNAT-I) in the Danish specialised palliative care setting

PURPOSE

The Carer Support Needs Assessment Tool Intervention (CSNAT-I) has shown positive effects in the Danish specialised palliative care (SPC) setting. Here, we explore the process, content, and experiences of delivering the CSNAT-I.

METHODS

Data were collected during a stepped wedge cluster randomised controlled trial investigating the impact of the CSNAT-I in the Danish SPC setting in 2018-2019. Data were obtained from the CSNAT (tool) completed by caregivers, from health care professionals' (HCPs') written documentation of the CSNAT-I, and from semi-structured interviews with HCPs.

RESULTS

The study population consisted of the 130 caregivers receiving a first CSNAT-I within 13 days of study enrolment, the 93 caregivers receiving a second CSNAT-I 15-27 days after enrolment, and the 44 HCPs delivering the intervention. Top three domains of unmet caregiver support needs reported in the CSNAT-I were: "knowing what to expect in the future," "dealing with feelings and worries," and "understanding the illness." These domains together with "knowing who to contact if concerned" and "talking to the patient about the illness" were also the domains most frequently prioritised for discussion with HCPs. According to HCPs, most often support delivered directly by HCPs themselves during the actual contact (e.g., listening, advice, information) was sufficient. Overall, HCPs experienced the CSNAT-I as constructive and meaningful, and difficulties in delivering the intervention were rarely an issue.

CONCLUSION

The support needs reported by caregivers confirm the relevance of the CSNAT-I. HCPs' overall experiences of the clinical feasibility and relevance of the CSNAT-I were very positive. ClinicalTrials.gov ID: NCT03466580. Date of registration: March 1, 2018.

Effects of psychosocial interventions on psychological outcomes among caregivers of advanced cancer patients: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to synthesize the effectiveness of psychosocial interventions on caregivers of advanced cancer patients, in comparison with usual care, on caregivers' quality of life (QoL), anxiety, and depression symptoms.

METHODS

Comprehensive searches for published and unpublished studies were performed using nine electronic databases, two trial registers, and reference lists of included studies. Two reviewers independently screened, appraised, and extracted data. The Cochrane risk of bias tool was used to appraise the methodological quality of included studies, while the Cochrane data extraction tool was used to elicit relevant information. Meta-analysis, narrative analysis, and sensitivity analysis were conducted to synthesize data. Standardized mean differences (SMD) represented effects of psychosocial interventions.

RESULTS

Fifteen randomized controlled trials were included in this review. At post-intervention, findings revealed a significant small pooled effect size (SMD = 0.45) on QoL and significant moderate effect on depression (SMD = - 0.65). However, a small non-significant pooled effect size was observed on anxiety (SMD = - 0.24). At follow-up assessments, effect sizes of all outcomes were small and non-significant. Overall quality of evidence was rated very low for all outcomes and most studies had unclear or high risk of bias. Thus, results should be interpreted with caution.

CONCLUSION

Psychosocial interventions were effective in improving QoL and depression among caregivers of persons with advanced cancer. However, future randomized control trials with lower risk of bias, larger sample size, detailed participant characteristics, and informative interventions are desirable.

"We Have to Be Strong Ourselves": Exploring the Support Needs of Informal Carers of Aboriginal and Torres Strait Islander People with Cancer

Informal carers provide an important role in supporting people with cancer. Aboriginal and Torres Strait Islander peoples experience higher cancer mortality than other Australians. To date, very little is known about the support needs of carers of Aboriginal and Torres Strait Islander adults with cancer. This article explored these needs through a qualitative study. Twenty-two semi-structured qualitative interviews and one focus group were conducted with carers of Aboriginal and Torres Strait Islander adults with cancer (n = 12) and Aboriginal and Torres Strait Islander cancer survivors (n = 15) from Queensland, Australia. Half of the carers interviewed were Aboriginal or Torres Strait Islander Australians. Interviews were transcribed, coded and thematically analysed following an interpretive phenomenological approach. Thematic analysis of carer and survivor interviews revealed four key themes relating to carers’ needs: managing multiple responsibilities; maintaining the carer’s own health and wellbeing; accessing practical support and information; and engaging with the health system. Within these overarching themes, multiple needs were identified including specific needs relevant for carers of Aboriginal and Torres Strait Islander peoples, such as advocating for the patient; accessing Indigenous support services and health workers; and ensuring that the cultural needs of the person are recognised and respected. Identifying the needs of informal carers of Aboriginal and Torres Strait Islander cancer patients will enable greater understanding of the support that carers require and inform the development of strategies to meet these areas of need.

Palliative radiotherapy combined with stent insertion to reduce recurrent dysphagia in oesophageal cancer patients: the ROCS RCT

BACKGROUND

Most patients with oesophageal cancer present with incurable disease. For those with advanced disease, the mean survival is 3-5 months. Treatment emphasis is therefore on effective palliation, with the majority of patients requiring intervention for dysphagia. Insertion of a self-expanding metal stent provides rapid relief but dysphagia may recur within 3 months owing to tumour progression. Evidence reviews have called for trials of interventions combined with stenting to better maintain the ability to swallow.

OBJECTIVES

The Radiotherapy after Oesophageal Cancer Stenting (ROCS) study examined the effectiveness of palliative radiotherapy, combined with insertion of a stent, in maintaining the ability to swallow. The trial also examined the impact that the ability to swallow had on quality of life, bleeding events, survival and cost-effectiveness.

DESIGN

A pragmatic, multicentre, randomised controlled trial with follow-up every 4 weeks for 12 months. An embedded qualitative study examined trial experiences in a participant subgroup.

SETTING

Participants were recruited in secondary care, with all planned follow-up at home.

PARTICIPANTS

Patients who were referred for stent insertion as the primary management of dysphagia related to incurable oesophageal cancer.

INTERVENTIONS

Following stent insertion, the external beam radiotherapy arm received palliative oesophageal radiotherapy at a dose of 20 Gy in five fractions or 30 Gy in 10 fractions.

MAIN OUTCOME MEASURES

The primary outcome was the difference in the proportion of participants with recurrent dysphagia, or death, at 12 weeks. Recurrent dysphagia was defined as deterioration of ≥ 11 points on the dysphagia scale of the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire oesophago-gastric module questionnaire. Secondary outcomes included quality of life, bleeding risk and survival.

RESULTS

The study recruited 220 patients: 112 were randomised to the usual-care arm and 108 were randomised to the external beam radiotherapy arm. There was no evidence that radiotherapy reduced recurrence of dysphagia at 12 weeks (48.6% in the usual-care arm compared with 45.3% in the external beam radiotherapy arm; adjusted odds ratio 0.82, 95% confidence interval 0.40 to 1.68; p = 0.587) and it was less cost-effective than stent insertion alone. There was no difference in median survival or key quality-of-life outcomes. There were fewer bleeding events in the external beam radiotherapy arm. Exploration of patient experience prompted changes to trial processes. Participants in both trial arms experienced difficulty in managing the physical and psychosocial aspects of eating restriction and uncertainties of living with advanced oesophageal cancer.

LIMITATIONS

Change in timing of the primary outcome to 12 weeks may affect the ability to detect a true intervention effect. However, consistency of results across sensitivity analyses is robust, including secondary analysis of dysphagia deterioration-free survival.

CONCLUSIONS

Widely accessible palliative external beam radiotherapy in combination with stent insertion does not reduce the risk of dysphagia recurrence at 12 weeks, does not have an impact on survival and is less cost-effective than inserting a stent alone. Reductions in bleeding events should be considered in the context of patient-described trade-offs of fatigue and burdens of attending hospital. Trial design elements including at-home data capture, regular multicentre nurse meetings and qualitative enquiry improved recruitment/data capture, and should be considered for future studies.

FUTURE WORK

Further studies are required to identify interventions that improve stent efficacy and to address the multidimensional challenges of eating and nutrition in this patient population.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN12376468 and Clinicaltrials.gov NCT01915693.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 31. See the NIHR Journals Library website for further project information.

The determinants of the intensity of home-based informal care among cancer patients in receipt of home-based palliative care

BACKGROUND

Understanding the determinants of the intensity of informal care may assist policy makers in the identification of supports for informal caregivers. Little is known about the utilization of informal care throughout the palliative care trajectory.

AIM

The purpose of this study was to analyze the intensity and determinants of the use of informal care among cancer patients over the palliative care trajectory.

DESIGN

This was a longitudinal, prospective cohort design conducted in Canada. Regression analysis using instrumental variables was applied.

SETTING/PARTICIPANTS

From November 2013 to August 2017, a total of 273 caregivers of cancer patients were interviewed biweekly over the course of the care recipient's palliative care trajectory. The outcome was the number of hours of informal care provided by unpaid caregivers, that is, hours of informal care.

RESULTS

The number of hours of informal care increased as patients approached death. Home-based nursing care complemented, and hence, increased the provision of informal care. Patients living alone and caregivers who were employed were associated with the provision of fewer hours of informal care. Spousal caregivers provided more hours of informal care. Patient's age, sex, and marital status, and caregiver's age, sex, marital status, and education were associated with the number of hours of informal care.

CONCLUSIONS

The intensity of informal care was determined by predisposing, enabling, and needs-based factors. This study provides a reference for the planning and targeting of supports for the provision of informal care.

Developing a family-reported measure of experiences with home-based pediatric palliative and hospice care: a multi-method, multi-stakeholder approach

Background

Many children with serious illnesses are receiving palliative and end-of-life care from pediatric palliative and hospice care teams at home (PPHC@Home). Despite the growth in PPHC@Home, no standardized measures exist to evaluate whether PPHC@Home provided in the U.S. meets the needs and priorities of children and their families.

Methods

We developed and conducted a preliminary evaluation of a family-reported measure of PPHC@Home experiences using a multi-method, multi-stakeholder approach. Our instrument development process consisted of four phases. Item identification and development (Phase 1) involved a comprehensive literature search of existing instruments, guidelines, standards of practice, and PPHC@Home outcome studies, as well as guidance from a PPHC stakeholder panel. Phase 2 involved the initial item prioiritization and reduction using a discrete choice experiment (DCE) with PPHC professionals and parent advocates. Phase 3 involved a second DCE with bereaved parents and parents currently receiving care for their child to further prioritize and winnow the items to a set of the most highly-valued items. Finally, we conducted cognitive interviews with parents to provide information about the content validity and clarity of the newly-developed instrument (Phase 4).

Results

Items were compiled predominantly from three existing instruments. Phase 2 participants included 34 PPHC providers, researchers, and parent advocates; Phase 3 participants included 47 parents; and Phase 4 participants included 11 parents. At the completion of Phase 4, the Experiences of Palliative and Hospice Care for Children and Caregivers at Home (EXPERIENCE@Home) Measure contains 22 of the most highly-valued items for evaluating PPHC@Home. These items include “The care team treats my child’s physical symptoms so that my child has as good a quality of life as possible”, “I have regular access to on-call services from our care team”, and “The nurses have the knowledge, skills, and experience to support my child’s palliative or hospice care at home.”

Conclusions

The EXPERIENCE@Home Measure is the first known to specifically measure family-reported experiences with PPHC@Home in the U.S. Future work will include formal psychometric evaluation with a larger sample of parents, as well as evaluation of the clinical utility of the instrument with PPHC@Home teams.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-020-00703-0.

The power of informal cancer caregivers' writings: results from a thematic and narrative analysis

Background

Cancer is a disease that disrupts not only the patient’s life, but that of the entire family as well, from a care, organizational, and emotional perspective. Patients share their experience of illness frequently with their informal caregiver (IC), a partner, son/daughter, friend, volunteer, or any other person in the family or social network who offers to support them during their clinical journey. The purpose of this study was to investigate ICs’ still unknown cancer experiences through the stories of IC participants in a Literary Artistic Competition the Centro di Riferimento Oncologico di Aviano (CRO) IRCSS organized, and understand the themes that emerged from their texts and hence, the power of expressive writing.

Materials and methods

A qualitative study was carried out on literary texts using Mishler’s three levels of narrative analysis: thematic (to detect themes and subthemes); structural (to support the thematic level), and performative (to understand the narratives’ meaning). In addition, the narratives were classified based on Kleinman and Frank’s models. A particular focus was placed on the language of the narratives to identify figures of speech, e.g., metaphors related to cancer.

Results

Seven main themes emerged from the 40 stories’ thematic analysis: perceptions of the disease; biographical breakdown; relationships; transformation of the sick body; IC’s role; encounter with death; and strength of memory. The ICs’ stories also highlighted the strengths and weaknesses of the patient’s clinical pathway. ICs are a resource not only for the patient, who, thanks to them, is assured of continuous assistance but also for the healthcare organization, above all because they serve a relational role as a “bridge” between patients and healthcare workers. ICs have important messages to offer to healthcare organizations. If involved adequately, they can provide a strategic strength in supporting patients and healthcare workers themselves. The in-depth analysis of the themes and subthemes in this study led the authors to hypothesize that expressive writing benefit ICs with respect to the possibility of sharing their experiences with others and giving evidence of their role. Their stories are a testimony that can help those who face a similar experience.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-020-05901-3.

A qualitative study of bereaved family caregivers: feeling of security, facilitators and barriers for rural home care and death for persons with advanced cancer

BACKGROUND

For cancer patients and their family, an important factor that determines the choice to die at home is the caregivers' feeling of security when caring for the patient at home. Support to caregivers from healthcare professionals is important for the feeling of security. In rural areas, long distances and variable infrastructure may influence on access to healthcare services. This study explored factors that determined the security of caregivers of patients with advanced cancer who cared for the patients at home at the end of life in the rural region of Sogn og Fjordane in Norway, and what factors that facilitated home death.

METHODS

A qualitative study using semi-structured in-depth interviews with bereaved with experience from caring for cancer patients at home at the end of life was performed. Meaning units were extracted from the transcribed interviews and divided into categories and subcategories using Kvale and Brinkmann's qualitative method for analysis.

RESULTS

Ten bereaved caregivers from nine families where recruited. Five had lived together with the deceased. Three main categories of factors contributing to security emerged from the analysis: "Personal factors", "Healthcare professionals" and "Organization" of healthcare. Healthcare professionals and the organization of healthcare services contributed most to the feeling of security.

CONCLUSION

Good competence in palliative care among healthcare professionals caring for patients with advanced cancer at home and well- organized palliative care services with defined responsibilities provided security to caregivers caring for advanced cancer patients at home in Sogn og Fjordane.

Improving regional care in the last year of life by setting up a pragmatic evidence-based Plan-Do-Study-Act cycle: results from a cross-sectional survey

OBJECTIVES

To set up a pragmatic Plan-Do-Study-Act cycle by analysing patient experiences and determinants of satisfaction with care in the last year of life.

DESIGN

Cross-sectional postbereavement survey.

SETTING

Regional health services research and development structure representing all health and social care providers involved in the last year of life in Cologne, a city with 1 million inhabitants in Germany.

PARTICIPANTS

351 bereaved relatives of adult decedents, representative for age and gender, accidental and suspicious deaths excluded.

RESULTS

For the majority (89%) of patients, home was the main place of care during their last year of life. Nevertheless, 91% of patients had at least one hospital admission and 42% died in hospital. Only 60% of informants reported that the decedent had been told that the disease was leading to death. Hospital physicians broke the news most often (58%), with their communication style often (30%) being rated as 'not sensitive'. Informants indicated highly positive experiences with care provided by hospices (89% 'good') and specialist palliative home care teams (87% 'good'). This proportion dropped to 41% for acute care hospitals, this rating being determined by the feeling of not being treated with respect and dignity (OR=23.80, 95% CI 7.503 to 75.498) and the impression that hospitals did not work well together with other services (OR=8.37, 95% CI 2.141 to 32.71).

CONCLUSIONS

Following those data, our regional priority for action now is improvement of care in acute hospitals, with two new projects starting, first, how to recognise and communicate a limited life span, and second, how to improve care during the dying phase. Results and further improvement projects will be discussed in a working group with the city of Cologne, and repeating this survey in 2 years will be able to measure regional achievements.

TRIAL REGISTRATION NUMBER

DRKS00011925.

'It's like trying to ice a cake that's not been baked': a qualitative exploration of the contextual factors associated with implementing an evidence-based information intervention for family carers at the end of life

Aim:

To explore the introduction of an evidence-based information intervention – the ‘Caring for Someone with Cancer’ booklet – within home care and end-of-life care, to inform future implementation and practice development within this setting.

Background:

Family carers’ contribution is crucial to enable care and death of people at home. The ‘Caring for Someone with Cancer’ booklet received positive responses from family carers and District Nurses and is an evidence-based intervention designed to support carers to deliver basic nursing tasks. Further feasibility work was required to establish how it should be implemented. Little is known about how to successfully translate interventions into practice, particularly within home care settings and end-of-life care.

Methods:

Implementation of the ‘Caring for Someone with Cancer’ booklet, utilising a qualitative case study approach, in four home care sites. Semi-structured interviews, informed by Normalization Process Theory (NPT), were undertaken at implementation sites in May 2016–June 2017. Participants were generalist and specialist nurses, managers, and Healthcare Assistants (HCAs). A framework approach to analysis was adopted.

Findings:

Forty-five members of staff participated. Failed implementation was associated with organisational-level characteristics and conditions, including workforce composition and predictability of processes. Unstable work environments meant home care providers focused on short-term rather than long-term goals, precluding practice development. Staff’s perceptions of the time available to engage with and implement the intervention inhibited adoption, as many participants were “just getting through the day”. Implementation was successful in sites with explicit management support, including proactive implementation attempts by managers, which legitimatised the change process, and if all staff groups were engaged. To encourage uptake of evidence-based interventions in home care settings, practitioners should be given opportunities to critically reflect upon taken-for-granted practices. Future implementation should focus on work pertaining to the NPT construct ‘Collective Action’, including how staff interact and build confidence in new practices.

Determining the informational needs of family caregivers of people with intellectual disability who require palliative care: A qualitative study

OBJECTIVES

People with intellectual disabilities are living longer, and many require palliative care. There is a lack of evidence regarding information needs which may exist for their family caregivers. This study aimed to determine the informational needs of family caregivers of people with intellectual disabilities who require palliative care.

METHODS

A qualitative, exploratory design was underpinned by the Transactional Model of Stress and Coping and the Transformative Paradigm. The study involved five Health and Social Care (HSC) Trusts and two Hospices in one region of the United Kingdom. Family caregivers (n = 10) participated in individual interviews. HSC professionals' (n = 28) perceptions of informational needs were explored within focus groups (n = 6).

RESULTS

Family caregivers reported information needs chiefly concerning the disease, financial entitlements, and practical support which could change over the disease trajectory. Findings evidence the expertise of long-term family caregivers, prior to the end of life. Palliative care and intellectual disability teams acknowledged their role to work in partnership and facilitate access to information. Recommendations were mapped onto a co-designed logic model.

SIGNIFICANCE OF RESULTS

New insights into the specific informational needs of this family caregiving population. A co-designed logic model presents these needs and how they may be addressed. Central co-ordinators have been advocated for these caregivers. This model could have international applicability for similar family carers, supporting people with other disabilities or cognitive impairment, and should be further explored.

Home-Based Educational Programs for Management of Dyspnea: A Systematic Literature Review

Dyspnea or breathlessness is a symptom of a plethora of diseases; despite that its management poses a challenge, it leads to frequent hospitalizations and a poor quality of life. In lung cancer, dyspnea may appear at any time of the disease but mainly during the end-of-life period. This article aims to explore the effectiveness of home-based educational programs for the management of dyspnea. This is a systematic review. The inclusion criteria were studies published between 2000 and 2018, and structured nurse-led home educational programs for the management of dyspnea due to cancer. The search via PUBMED, COCHRANE, EBSCO, and Google Scholar was worldwide for English- and Greek-language articles. The keywords included “education, program, intervention, patient, dyspnea, breathlessness, cancer, home, nurse.” The review was expanded to dyspnea being due to any chronic disease as it gave only one research article for lung cancer. The review identified seven research articles evaluating the effectiveness of various home-based educational programs for dyspnea management due to chronic obstructive pulmonary disease, heart failure, and lung cancer. They showed that a structured home-based educational program is of benefit for the patients by improving their dyspnea levels and their quality of life. There is the need to evaluate the benefits of home-based educational programs for cancer patients with dyspnea at home either as part of a symptom alone support program or as part of the general support given to cancer patients at home.

Family members' experiences and expectations of self-management counseling while caring for a person with chronic obstructive pulmonary disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to identify and synthesize existing evidence on the experiences and expectations of self-management counseling of adult family members who are informal caregivers of a person with chronic obstructive pulmonary disease (COPD) in the context of inpatient or outpatient care.

INTRODUCTION

Chronic obstructive pulmonary disease is the fourth leading cause of mortality and morbidity worldwide. It is a progressive, lifelong and unpredictable disease. As the disease progresses, both the people with COPD and their family members require information and practical skills to manage the disease. The role of family members is particularly important at the advanced stage of COPD. This systematic review examined family members' experiences and expectations of self-management counseling.

INCLUSION CRITERIA

This review considered qualitative studies that investigated adult (older than18 years) family members' experiences or expectations of COPD self-management counseling in the context of inpatient or outpatient care. "Family member" refers to a person who is an informal caregiver because of his or her relationship to the person with COPD.

METHODS

A three-step search strategy was utilized in this review. The search strategy aimed to find published and unpublished studies in English and Finnish. The databases MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish medical bibliographic database, Medic, were searched. The search was conducted in December 2015 and updated in September 2018. Titles and abstracts were screened by two independent reviewers for the review's inclusion criteria. Eligible studies were then critically appraised by two independent reviewers for methodological quality. The findings and illustrations of the findings were extracted and assigned a level of credibility. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Ten papers were selected for inclusion in this review. These studies were published from 2002 to 2017. The quality of all included studies was at least moderate. Each study had a total score between 7 and 10 on the JBI Critical Appraisal Checklist for Qualitative Research. The following four synthesized findings were aggregated from nine categories and 39 study findings: i) Family members' experiences with unresponsive behavior from health professionals, ii) Family members' experiences of unmet needs in self-management counseling, iii) Family members' information needs concerning COPD management, and iv) Family members' information needs concerning coping strategies.

CONCLUSIONS

The synthesized findings indicate that family members are frustrated by the shortcomings of self-management counseling. They also feel unprepared for and uncertain about their caring role. They need more information about COPD and coping strategies for COPD. Counseling is essential to high-quality care and should be offered to family members caring for a loved one at any stage of COPD.

Comparison of the experience of caregiving at end of life or in hastened death: a narrative synthesis review

Background

End-of-life caregiving frequently is managed by friends and family. Studies on hastened death, including aid in dying or assisted suicide, indicate friends and family also play essential roles before, during, and after death. No studies have compared the experiences of caregivers in hastened and non-hastened death. The study aim is to compare end-of-life and hastened death caregiving experience using Hudson’s modified stress-coping model for palliative caregiving.

Method

Narrative synthesis of qualitative studies for caregivers at end of life and in hastened death, with 9946 end-of life and 1414 hastened death qualitative, peer-reviewed research articles extracted from MEDLINE, CINAHL, Web of Science, and PsycINFO, published between January 1998 and April 2020.

Results

Forty-two end-of-life caregiving and 12 hastened death caregiving articles met inclusion criteria. In both end-of-life and hastened death contexts, caregivers are motivated to ease patient suffering and may put their own needs or feelings aside to focus on that priority. Hastened death caregivers’ expectation of impending death and the short duration of caregiving may result in less caregiver burden. Acceptance of the patient’s condition, social support, and support from healthcare professionals all appear to improve caregiver experience. However, data on hastened death are limited.

Conclusion

Caregivers in both groups sought closeness with the patient and reported satisfaction at having done their best to care for the patient in a critical time. Awareness of anticipated death and support from healthcare professionals appear to reduce caregiver stress. The modified stress-coping framework is an effective lens for interpreting caregivers’ experiences at end of life and in the context of hastened death.

A randomized clinical trial assessing a pragmatic intervention to improve supportive care for family caregivers of patients with lung cancer

OBJECTIVE

Family caregivers (FCs) of cancer patients often experience high distress. This randomized clinical trial assessed the feasibility and preliminary effects of an intervention to improve FC supportive care.

METHOD

A pragmatic and minimal intervention to improve FC supportive care was developed and pretested with FCs, oncology team, and family physicians to assess its relevance and acceptability. Then, FCs of lung cancer patients were randomized to the intervention or the control group. The intervention included (1) systematic FC distress screening and problem assessment in the first months after their relative cancer diagnosis, and every 2 months after; (2) privileged contact with an oncology nurse to address FC problems, provide emotional support and skills to play their caregiving role; (3) liaison with the family physician of FCs reporting high distress (distress thermometer score ≥4/10) to involve them in the provision of supportive care. Distress, the primary outcome, was measured every 3 months, for 9 months. Secondary outcomes included quality of life, caregiving preparedness, and perceived burden. At the end of their participation, a purposive sample of FC from the experimental group was individually interviewed to assess the intervention usefulness. Content analysis was performed.

RESULTS

A total of 109 FCs participated in the trial. FC distress decreased over time, but this reduction was observed in both groups. Similar results were found for secondary outcomes. However, FCs who received the intervention felt better prepared in caregiving than controls (p = 0.05). All 10 interviewed FCs valued the intervention, even though they clearly underused it. Knowing they could contact the oncology nurse served as a security net.

SIGNIFICANCE OF RESULTS

Although the intervention was not found effective, some of its aspects were positively perceived by FCs. As many of them experience high distress, an improved intervention should be developed to better support them.

WeChat app-based reinforced education improves the quality of opioid titration treatment of cancer-related pain in outpatients: a randomized control study

Background

As inadequate pain communication contributes to difficulties in optimizing outcomes of outpatients, we investigated the effect of reinforced education using WeChat App to the opioid titration treatment of cancer-related pain in the outpatient setting.

Methods

We conducted a prospective study to compare reinforced education using Wechat with care as usual from February to December 2019. Patients in the reinforced education group received reinforced education via Wechat, while those in the control group received care as usual. Effect measurements for both groups are carried out with questionnaires at the baseline and 3 days later. Questionnaires include pain intensity (NRS), treatment-related adverse events, cancer-related quality of life (QOL), sleep (PSQI), satisfaction, anxiety (GAD-7) and depression (PHQ-9). Number of patients whose NRS reduced to less than three points in 24 h was the primary outcomes. Secondary outcomes included treatment-related adverse events, cancer-related quality of life, sleep, satisfaction, anxiety and depression.

Results

Although there was no significant difference regarding pain intensity (NRS) between the two groups at 72 h, the rate of NRS that reduced to less than three points in 24 h was significantly higher in the Wechat group than in the control group. Patients’ satisfaction was significantly higher in the Wechat group than in the control group. There was no significant difference between the two groups regarding the other findings at 72 h, including pain intensity (NRS), cancer-related quality of life (QOL), anxiety (GAD-7), depression (PHQ-9), and sleep (PSQI). However, no significant difference was found between the two groups for constipation, nausea, vomiting, dizziness, somnolence, pruritus, loss of consciousness, and death.

Conclusions

Our results indicated that receiving instructions delivered by Wechat resulted an increased number of patients with good pain control and better satisfaction. The study provided insight into the effectiveness of the reinforced education using a Wechat app delivered by a doctor to outpatients in the titration treatment of cancer-related pain.

Trial registration

This study was registered at chictr.org (Registration number: ChiCTR1900021150, Date of Registration: January 30, 2019).

Developing and Assessing the Effectiveness of a Nurse-Led Home-Based Educational Programme for Managing Breathlessness in Lung Cancer Patients. A Feasibility Study

Introduction: Breathlessness is the most common and refractory symptom in lung cancer patients. Even though various educational programmes have been developed, only a few were intended for implementation in the home setting for its management.

Aim: Feasibility of a study for implementing a nurse-led educational programme for breathlessness management of lung cancer patients at home.

Method: A randomized feasibility study was undertaken between February 2017 and October 2018. Patients were recruited through referral from oncologists from two oncology centers in Cyprus under certain inclusion and exclusion criteria. Patients were randomized in the intervention or control group via a computer programme, and their named family caregivers (f.c.) were allocated in the same group. Participants were not blinded to group assignment. The intervention consisted of a PowerPoint presentation and implementation of three non-pharmacological interventions. The control group received usual care. Patients were assessed for breathlessness, anxiety, and depression levels, whereas f.c. were assessed for anxiety, depression, and burden levels. F.c. also assessed patients' dyspnea level. The duration of the study process for both the intervention and control group was over a period of 4 weeks.

Results: Twenty-four patients and their f.c. (n = 24) were allocated equally in the intervention and control group. Five patients withdrew, and the final sample entered analysis was 19 patients and 19 family caregivers. In the intervention group n = 11 + 11, and in the control group n = 8 + 8. In the intervention group patients' breathlessness and anxiety levels showed improvement and their f.c.s in the anxiety and burden levels. Major consideration was the sample size and the recruitment of the patients by the referring oncologists. Attrition was minor during the study process. No harm was recorded by the participants of the study.

Conclusions: The study provided evidence of the feasibility of the implementation of the educational programme. For the future definitive study major consideration should be patients' recruitment method in order to achieve adequate sample size. Moreover, qualitative data should be collected in relation to the intervention and the involvement of f.c. The feasibility study was registered to the Cyprus Bioethics Committee with the registration number 2016/16. There was no funding of the study.

Palliative care utilisation: family carers' behaviours and determinants-a qualitative interview study

OBJECTIVES

Most research on starting palliative care focuses on the role of healthcare services and professional carers. However, patients and their family carers may also play a role. Especially opportunities for starting palliative care might exist among family carers. This study focused on family carers by identifying their behaviours and underlying determinants that might contribute to starting palliative care.

METHODS

A qualitative study with 16 family carers of deceased persons who used palliative care was conducted using semistructured, face-to-face interviews. Constant comparison analysis was used to identify groups of behaviours that influenced starting palliative care and related determinants. The behavioural determinants were matched with concepts in existing behavioural theories. A preliminary behavioural model was developed.

RESULTS

Most reported behaviours regarding starting palliative care were related to communicating with the seriously ill person, other family members and professional carers; seeking information and helping the seriously ill person process information from professional carers; and organising and coordinating care. Determinants facilitating and hindering these behaviours included awareness (eg, of poor health), knowledge (eg, concerning palliative care), attitudes (eg, negative connotations of palliative care) and social influences (eg, important others' opinions about palliative care).

CONCLUSIONS

This study identified relevant family carers' behaviours and related determinants that can contribute to starting palliative care. As these determinants are changeable, the palliative care behavioural model that resulted from this study can serve as a basis for the development of behavioural interventions aiming at supporting family carers in performing behaviours that might contribute to starting palliative care.

Profiles of family caregivers of patients at the end of life at home: a Q-methodological study into family caregiver' support needs

BACKGROUND

Family caregivers of patients at the end of life often experience care-related burden. To prevent caregiver burden and to enhance the capacity to provide care it is important to have insight in their support needs. The purpose of this study was to identify profiles of family caregivers who provide care to patients at the end of life at home.

METHODS

A Q-methodological study was conducted in which family caregivers ranked 40 statements on support needs and experiences with caregiving. Thereafter they explained their ranking in an interview. By-person factor analysis was used to analyse the rankings and qualitative data was used to support the choice of profiles. A set of 41 family caregivers with a variety on background characteristics who currently or recently provided care for someone at the end of life at home were included.

RESULTS

Four distinct profiles were identified; profile (1) those who want appreciation and an assigned contact person; profile (2) was bipolar. The positive pole (2+) comprised those who have supportive relationships and the negative pole (2-) those who wish for supportive relationships; profile (3) those who want information and practical support, and profile (4) those who need time off. The profiles reflect different support needs and experiences with caregiving.

CONCLUSIONS

Family caregivers of patients at the end of life have varying support needs and one size does not fit all. The profiles are relevant for healthcare professionals and volunteers in palliative care as they provide an overview of the main support needs among family caregivers of patients near the end of life. This knowledge could help healthcare professionals giving support.

Cost-Utility Analyses of Interventions for Informal Carers: A Systematic and Critical Review

BACKGROUND

Demographic and epidemiological changes place an increasing reliance on informal carers. Some support programmes exist, but funding is often limited. There is a need for economic evaluation of interventions for carers to assist policymakers in prioritizing carer support.

OBJECTIVE

Our aim was to systematically review and critically appraise cost-utility analyses of interventions for informal carers, in order to assess the methods employed and the quality of the reporting.

METHODS

A systematic review of databases was conducted using MEDLINE, Embase, PsycINFO, and EconLit of items published between 1950 and February 2019. Published studies were selected if they involved a cost-utility analysis of an intervention mainly or jointly targeting informal carers. The reporting quality of economic analyses was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

RESULTS

An initial set of 1364 potentially relevant studies was identified. The titles and the abstracts were then screened, resulting in the identification of 62 full-text articles that warranted further assessment of their eligibility. Of these, 20 economic evaluations of informal carer interventions met the inclusion criteria. The main geographical area was the UK (n = 11). These studies were conducted in mental and/or behavioural (n = 15), cardiovascular (n = 3) or cancer (n = 2) clinical fields. These cost-utility analyses were based on randomized clinical trials (n = 16) and on observational studies (n = 4), of which only one presented a Markov model-based economic evaluation. Four of the six psychological interventions were deemed to be cost effective versus two of the four education/support interventions, and four of the nine training/support interventions. Two articles achieved a CHEERS score of 100% and nine of the economic evaluations achieved a score of 85% in terms of the CHEERS criteria for high-quality economic studies.

CONCLUSIONS

Our critical review highlights the lack of cost-utility analyses of interventions to support informal carers. However, it also shows the relative prominence of good reporting practices in these analyses that other studies might be able to build on.

Development and validation of 'caring ability of family caregivers of patients with cancer scale (CAFCPCS)'

AIM

Family caregivers have limited abilities that make them vulnerable to the care needs of patients. Therefore, it seems necessary to evaluate their caring ability. The aim of this study was to design an instrument for assessing the caring ability of family caregivers of cancer patients.

METHODS

This was a sequential exploratory mixed-method study, carried out in two qualitative and quantitative phases. The concept of caring ability and its dimensions were explained using conventional content analysis in the qualitative phase. The research participants included 41 family caregivers of cancer patients and professional caregivers who were selected using purposeful sampling method until reaching data saturation. The scale items were designed using the results of the qualitative phase of the study, as well as the review of relevant literature. In the quantitative phase, the scale was validated using content and face validity, construct validity, as well as internal consistency and stability.

RESULTS

The primary item pool was prepared in 108 items. Content validity was determined using CVR with a cut-off point (0.62), CVI with a cut-off point (0.8) and kappa coefficient (κ) (>0.75). The validity of 72 items was confirmed. Then, the overlapping items were merged and eventually the 45-item scale entered the face validity stage and five items with an impact factor < 1.5 were omitted. Results of KMO = 0.904 and Bartlett = 6184.012 (p < 0.001) justified the need for factor analysis. Scree plot indicates five factors with eigenvalues above 1 and 67.7% of the total variance, including 'Effective role play, Fatigue and Surrender, Trust, Uncertainty, and Caring ignorance'. Reliability of the 31-item instrument indicated a Cronbach's alpha coefficient of 0.93 and ICC of 0.94.

CONCLUSIONS

Caring abilities scale (CAI) of family caregivers of patients with cancer is a valid and reliable instrument that can assess caregivers' caring ability.

The impact of population ageing on end-of-life care in Scotland: projections of place of death and recommendations for future service provision

BACKGROUND

Global annual deaths are rising. It is essential to examine where future deaths may occur to facilitate decisions regarding future service provision and resource allocation.

AIMS

To project where people will die from 2017 to 2040 in an ageing country with advanced integrated palliative care, and to prioritise recommendations based on these trends.

METHODS

Population-based trend analysis of place of death for people that died in Scotland (2004-2016) and projections using simple linear modelling (2017-2040); Transparent Expert Consultation to prioritise recommendations in response to projections.

RESULTS

Deaths are projected to increase by 15.9% from 56,728 in 2016 (32.8% aged 85+ years) to 65,757 deaths in 2040 (45% aged 85+ years). Between 2004 and 2016, proportions of home and care home deaths increased (19.8-23.4% and 14.5-18.8%), while the proportion of hospital deaths declined (58.0-50.1%). If current trends continue, the numbers of deaths at home and in care homes will increase, and two-thirds will die outside hospital by 2040. To sustain current trends, priorities include: 1) to increase and upskill a community health and social care workforce through education, training and valuing of care work; 2) to build community care capacity through informal carer support and community engagement; 3) to stimulate a realistic public debate on death, dying and sustainable funding.

CONCLUSION

To sustain current trends, health and social care provision in the community needs to grow to support nearly 60% more people at the end-of-life by 2040; otherwise hospital deaths will increase.

Informational needs of family caregivers of people with intellectual disability who require palliative care: a two-phase integrative review of the literature

BACKGROUND:

People with intellectual disabilities are living longer, with increasingly complex needs and their family caregivers may have a broad scope of unmet needs.

AIMS:

To identify the most common needs of family caregivers, to identify gaps in the literature, and distinguish the information needs of family caregivers of people with intellectual disabilities who require palliative care.

METHODS:

This two phase literature review used five electronic databases (CINAHL, PsycINFO, Medline, Cochrane and Pubmed). Phase 1 involved a review of systematic reviews of the needs of family caregivers across healthcare settings. Phase 2 explored the commonly reported information needs from phase 1, in relation to family caregivers of people with intellectual disability who require palliative care. There was no research explicit to the information needs of these family caregivers.

FINDINGS:

This review reveals potential information needs which may exist, guided by the palliative caregiving literature; alluding to information needs surrounding the disease, finances, and psychological or practical support.

CONCLUSION:

It is surmised that a greater scope of informational need exists for this population and further research is pertinent for international healthcare settings.

Online social support groups for informal caregivers of hospice patients with cancer

PURPOSE

Social support is an important factor in reducing caregiver burden, however, accessing social support via traditional means is often challenging for family caregivers of hospice patients. Online support groups may offer an effective solution. The present study sought to understand dynamics of online social support among family and other informal (e.g., friends) caregivers of hospice cancer patients in an online social support group. The primary aim of the study was to identify types of online social support and support-seeking behaviors, with a secondary aim to understand informal hospice caregivers' preferences for social support.

METHOD

Data used in this study were collected as part of a federally funded randomized clinical trial of an informal hospice cancer caregiver support intervention. Findings are based on directed and conventional content analysis of support group members' posts and comments-including text and images-and a sample of caregivers' exit interviews.

RESULTS

Analyses demonstrated that the majority of online support provided by group members was emotional support, followed by companionship support, appraisal support, and informational support. Instrumental support was rarely provided. Support was primarily elicited in an indirect manner through self-disclosure and patient updates, with few overt requests for support.

CONCLUSIONS

Findings suggest online social support groups can be a valuable resource for informal caregivers who are in need of emotional support and lack the ability to access face-to-face support groups. Clinical implications of this research to healthcare systems regarding the importance of incorporating nurses and other medical professionals as co-facilitators of online support groups are discussed.

When Death With Dementia Is “A Memory Seared in My Brain”: Caregivers’ Recommendations to Health Care Professionals

The purpose of this study is to determine family caregivers’ recommendations for professional health care professionals on how to help prepare them for the death of an elder with dementia. Purposive criterion sampling was employed to identify 30 bereaved caregivers of family members aged 65 and older who died with a dementia-related diagnosis. In-depth, qualitative interviews were conducted over a 12-month period, and qualitative content analysis was used to analyze the data. Three primary themes emerged: (a) Educate Caregivers, (b) Lead Caregivers, and (c) Provide a Caring and Compassionate Presence. The results highlight the importance of various health care professionals’ roles in preparing family caregivers for a death. In doing so, both the dying and their caregivers may have a better end-of-life experience with improved bereavement outcomes.

Development of an eHealth information resource for family carers supporting a person receiving palliative care on the island of Ireland

Background

Many people receiving palliative care wish to die at home. Often, support from family or friends is key to ensuring that this wish is fulfilled. However, carers report feeling underprepared to undertake this role. This paper describes the process of developing a consensus and evidence based website to provide core information to help people support someone receiving palliative care on the island of Ireland.

Methods

The project comprised three phases: (1) a review of systematic reviews facilitated the identification of core information needs; (2) content was developed in collaboration with a Virtual Reference Group (VRG) comprising patients, carers and professionals; and, (3) subject experts within the project team worked with a web developer to précis the agreed content and ensure it was in a format that was appropriate for a website. Members of the VRG were then invited to test and approve the website before it was made available to the general public.

Results

Nineteen systematic reviews identified nine consensus areas of core information required by carers; a description of palliative care; prognosis and treatment of the condition; medication and pain management; personal care; specialist equipment; locally available support services; what to do in an emergency; nutrition; and, support for the carer. This information was shared with the VRG and used to develop website content.

Conclusions

We engaged with service users and professionals to develop an evidence-based website addressing the agreed core information needs of non-professional carers who wish to provide palliative care to a friend or relative.

Family carer support in home and hospital: a cross-sectional survey of specialised palliative care

OBJECTIVES

To evaluate: (1) to what extent family carers of people supported by specialised palliative care services felt they had been provided with information, support and aftercare and (2) how this varied by type of palliative care service, length of enrolment and characteristics of deceased.

METHODS

A cross-sectional postal survey was conducted using a structured questionnaire with nine items on information, support and aftercare provided by specialised palliative care services to family carers. Flemish family carers of people who had made use of specialised palliative care services at home or in hospital were contacted.

RESULTS

Of all primary family carers (response rate of 53.5% resulting in n=1504), 77.7% indicated they were asked frequently by professionals how they were feeling. Around 75% indicated they had been informed about specific end-of-life topics and around 90% felt sufficiently supported before and immediately after the death. Family carers of people who had died in a palliative care unit, compared with other types of specialised palliative care services, indicated having received more information, support and aftercare.

CONCLUSIONS

Family carers evaluate the professional assistance provided more positively when death occurred in a palliative care unit. Policy changes might be needed to reach the same level of care across all specialised palliative care services.

Dyadic Interventions for Cancer Survivors and Caregivers: State of the Science and New Directions

OBJECTIVES

To describe caregiving and relationship challenges in cancer and the state of the science of dyadic interventions that target survivors and caregivers.

DATA SOURCES

Narrative review.

CONCLUSION

Viewing the survivor-caregiver dyad as the unit of care may improve multiple aspects of survivor and caregiver quality of life. However, several questions remain regarding how, why, and for whom dyadic interventions are effective.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should consider survivor, caregiver, and relationship needs when formulating supportive care protocols. Screening for survivor distress and extending distress screening to caregivers is an important first step in providing comprehensive psychosocial care.

Innovative Tools to Support Family Caregivers of Persons with Cancer: The Role of Information Technology

OBJECTIVES

To describe the current evidence of studies examining the use of information technology for family caregivers of persons with cancer. We highlight emerging technologies and trends and discuss ethical and practical implications.

DATA SOURCES

Review scientific studies and systematic reviews of technology use to support caregivers of persons with cancer.

CONCLUSION

The evidence base is growing; however, more studies are needed to test the effectiveness of technology.

IMPLICATIONS FOR NURSING PRACTICE

Several tools have potential to provide support to family caregivers but the selection of such tools needs to address access, privacy, interoperability, and usability considerations.