Experiences of carers supporting dying renal patients managed without dialysis

Feasibility and acceptability of the ShareD dEciSIon making for patients with kidney failuRE to improve end-of-life care intervention: A pilot multicentre randomised controlled trial

Background

Kidney failure is associated with a high disease burden and high mortality rates. National and international guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but implementation of these conversations within kidney services varies. We developed the DESIRE (ShareD dEciSIon-making for patients with kidney failuRE to improve end-of-life care) intervention from our studies investigating multiple decision maker needs and experiences of end-of-life care in kidney services. The DESIRE intervention's three components are a training programme for health professionals, a patient decision aid, and a kidney service consultation held to facilitate shared decision-making conversations about planning end-of-life care.

Objectives

To assess the feasibility and acceptability of integrating the DESIRE intervention within kidney services.

Design

A pilot study using a multicentre randomised controlled design.

Setting

Four Danish nephrology departments.

Participants

Patients with kidney failure who were 75 years of age or above, their relatives, and health professionals.

Methods

Patients were randomised to either the intervention or usual care. Feasibility data regarding delivering the intervention, the trial design, and outcome measures were collected through questionnaires and audio recordings at four points in time: before, during, post, and 3 months after the intervention. Acceptability data were collected through semi-structured interviews with patients and relatives, as well as a focus group with health professionals post the intervention.

Results

Twenty-seven patients out of the 32 planned were randomised either to the intervention (n= 14) or usual care (n= 13). In addition, four relatives and 12 health professionals participated. Follow-up was completed by 81 % (n= 22) of patient participants. We found that both feasibility and acceptability data suggested health professionals improved their decision support and shared decision-making skills via the training. Patient and relative participants experienced the intervention as supporting a shared decision-making process; from audio recordings, we showed health professionals were able to support proactively decision-making about end-of-life care within these consultations. All stakeholders perceived the intervention to be effective in promoting shared decision-making and relevant for supporting end-of-life care planning.

Conclusions

Participant feedback indicated that the DESIRE intervention can be integrated into practice to support patients, relatives, and health professionals in planning end-of-life care alongside the management of worsening kidney failure. Minimising exhaustion and enhancing engagement with the intervention should be a focus for subsequent refinement of the intervention.

Registration

The study has been registered at ClinicalTrials.gov with the identifier: NCT05842772. Date of first recruitment: March 20, 2023.

Preparing for responsive management versus preparing for renal dialysis in multimorbid older people with advanced chronic kidney disease (Prepare for Kidney Care): Study protocol for a randomised controlled trial

BACKGROUND

Chronic kidney disease (CKD) prevalence is steadily increasing, in part due to increased multimorbidity in our aging global population. When progression to kidney failure cannot be avoided, people need unbiased information to inform decisions about whether to start dialysis, if or when indicated, or continue with holistic person-centred care without dialysis (conservative kidney management). Comparisons suggest that while there may be some survival benefit from dialysis over conservative kidney management, in people aged 80 years and over, or with multiple health problems or frailty, this may be at the expense of quality of life, hospitalisations, symptom burden and preferred place of death. Prepare for Kidney Care aims to compare preparation for a renal dialysis pathway with preparation for a conservative kidney management pathway, in relation to quantity and quality of life in multimorbid, frail, older people with advanced CKD.

METHODS

This is a two-arm, superiority, parallel group, non-blinded, individual-level, multi-centre, pragmatic trial, set in United Kingdom National Health Service (NHS) kidney units. Patients with advanced CKD (estimated glomerular filtration rate < 15 mL/min/1.73 m2, not due to acute kidney injury) who are (a) 80 years of age and over regardless of frailty or multimorbidity, or (b) 65-79 years of age if they are frail or multimorbid, are randomised 1:1 to 'prepare for responsive management', a protocolised form of conservative kidney management, or 'prepare for renal dialysis'. An integrated QuinteT Recruitment Intervention is included. The primary outcome is mean total number of quality-adjusted life years during an average follow-up of 3 years. The primary analysis is a modified intention-to-treat including all participants contributing at least one quality of life measurement. Secondary outcomes include survival, patient-reported outcomes, physical functioning, relative/carer reported outcomes and qualitative assessments of treatment arm acceptability. Cost-effectiveness is estimated from (i) NHS and personal social services and (ii) societal perspectives.

DISCUSSION

This randomised study is designed to provide high-quality evidence for frail, multimorbid, older patients with advanced CKD choosing between preparing for dialysis or conservative kidney management, and healthcare professionals and policy makers planning the related services.

TRIAL REGISTRATION

ISRCTN, ISRCTN17133653 ( https://doi.org/10.1186/ISRCTN17133653 ). Registered 31 May 2017.

A qualitative study on the experiences of family caregivers of children with End Stage Kidney Disease (ESKD)

BACKGROUND

Family caregivers, mostly parents, are greatly involved in the care of their children with end stage kidney disease (ESKD) globally. Yet, the experiences of these caregivers and the demands placed on them by the caregiving role have not been explored or documented in Ghana. This study explored how caregiving affects the psychological, physical, social, and spiritual well-being of family caregivers of children with end stage kidney disease (ESKD) in Ghana.

METHODS

A phenomenological approach with the purposive sampling technique was used to gather data from 12 family caregivers of children with ESKD at a pediatric renal unit in Ghana. A semi-structured interview guide was constructed based on the constructs of the City of Hope Quality of Life (QoL) Family Caregiver Model and the research objectives. Colaizzi's thematic analysis approach was utilized to analyze data for this study. Themes were organized under the domains of the chosen model, and a new theme outside these domains was also generated.

RESULTS

The majority of the family caregivers experienced anxiety, fear, uncertainty, and hopelessness in response to the children's diagnosis and care. The thought of the possibility of the children dying was deeply traumatizing for our participants. Most participants reported bodily pains and physical ailments because of lifting and caring for the children. Financial constraint was also a key issue for all the family caregivers. Most of them received diverse support from their families and loved ones. Due to the demanding nature of the care, most family caregivers had to change or quit their jobs. They coped with the challenges through prayers, participating in religious activities, and being hopeful in God for healing.

CONCLUSION

All the family caregivers had their psychological well-being compromised as a result of the challenges they encountered physically, socially, and spiritually. Continuous psychosocial support, funding support, and review of policies on leave for civil workers with children diagnosed with ESKD are urgently required.

Decisional needs in people with kidney failure, their relatives and health professionals about end-of-life care options: A qualitative interview study

AIM

To investigate the decisional needs in Denmark of people with kidney failure, relatives, and health professionals when planning end-of-life care.

DESIGN

A qualitative interview study.

METHODS

Individual semi-structured interviews were carried out with people with kidney failure, relatives and health professionals from November 2021 to June 2022. Malterud's systematic text condensation was used to analyse transcripts.

RESULTS

A total of 13 patients, 10 relatives, and 12 health professionals were interviewed. Overall, four concepts were agreed on: (1) Talking about end of life is difficult, (2) Patients and relatives need more knowledge and information, (3) Health professionals need more tools and training, and (4) Experiencing busyness as a barrier to conversations about end of life.

CONCLUSION

People with kidney failure, relatives, and health professionals shared certain decisional needs while also having some different decisional needs about end-of-life care. To meet these various needs, end-of-life conversations should be systematic and organized according to the patients' needs and wishes.

IMPACT

Non-systematic end-of-life care decision-making processes limit patients' involvement. Patients and relatives need more knowledge about end-of-life care, and health professionals need more competences and time to discuss decisional needs. A shared decision-making intervention for people with kidney failure when making end-of-life care decisions will be developed.

REPORTING METHOD

This empirical qualitative research is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients, relatives, and health professionals have been involved throughout the research process as part of the research team and advisory board. The patients are people with kidney failure and the relatives are relatives of a person with kidney failure. For this study, the advisory board has particularly contributed to the validation of the invitation letter for participation, the interview guides and the preparation of the manuscript.

Investigating the Needs of Caregivers of Patients Suffering from Chronic Diseases: A Mixed-Method Study

Objectives

The objective of this study was to investigate the needs of carers of patients suffering from chronic diseases.

Material and Methods

The present study is a mixed approach, quantitative and qualitative. The study population consisted of 560 caregivers of patients with chronic diseases. The data collection was done with an improvised needs survey questionnaire, which included 57 questions. The questionnaire surveyed carers 'financial needs, social needs, psychological needs, and patients' education needs. The Cronbach-a index of the Patient Needs Survey was 0.956 and that of caregivers was 0.965. Carers' burden of care was assessed with The Zarit Burden Interview scale. The statistical analysis of the data was done with the statistical program IBM SPSS for Windows version 26.0.

Results

The main diseases of the patients were chronic renal failure (22.6%), multiple sclerosis (19%), cancer (19%), diabetes mellitus (7.1%), dementia (6%), and chronic obstructive pulmonary disease (6%). The majority of patients (82.1%) had health problems for more than 24 months. Caregivers provided 12.5 ± 8.3 h of daycare and cared for patients for more than 24 months (73.2%). Caregivers seek information from health professionals (4.41 ± 1.2), need more information (4.11 ± 1.4), feel stressed about the role of caregiver (3.91 ± 1.3), time available for vacation is limited (3.89 ± 1.4), time available for entertainment is limited (3.80 ± 1.3) and they feel intimidated with the role of carer (3.76 ± 1.3). The caregivers' charge was 42.4 ± 19.6. Most caregivers reported moderate to severe burdens.

Conclusion

Caregivers experience a lack of clear and comprehensible information about the treatment that caring patients receive, as well as a lack of ongoing care from health professionals.

The needs of families who care for individuals with kidney failure on comprehensive conservative care: A qualitative systematic review

BACKGROUND

Integrating the family of patients with kidney failure on comprehensive conservative care could benefit patients, families, and the health care system. However, there is a knowledge gap in this phenomenon since no systematic review has focused on the families' needs who care for individuals with kidney failure on comprehensive conservative care.

OBJECTIVES

To understand the primary needs of families who care for people with kidney failure on comprehensive conservative care.

METHOD

A systematic literature review of qualitative studies, followed by a content analysis was carried out. PubMed, CINAHL, and PsycINFO databases were used to search for articles published in English and Spanish between 2010 and 2021. The ENTREQ guideline was used for reporting.

RESULTS

Five relevant studies were included in this study. The analysis has allowed identifying key aspects of knowledge, psychological, social and spiritual needs of family members of patients with kidney failure on comprehensive conservative care.

CONCLUSIONS

This systematic review has revealed that families experience a lack of information and continuity of care by health care professionals. Added to this is the psychological burden they bear due to the feeling of indefinite care in time and uncertainty about the death of their loved one. All this, without the necessary support from their immediate family environment and social institutions. In light of these data, a paradigm shift in society and the health care received by these families is essential.

Experiences of Caregivers of Patients With Conservatively Managed Kidney Failure: A Mixed Methods Systematic Review

Background:

Older people with kidney failure often choose conservative kidney care. The experiences and quality of life (QOL) of caregivers who support them are incompletely characterized.

Objective:

To determine the burden, QOL, and understand experiences of caregivers supporting patients managed conservatively.

Design:

Systematic review of quantitative and qualitative studies.

Sources of information:

PubMed, Embase, PsycINFO, CINAHL, and MEDLINE electronic databases were systematically searched for quantitative and qualitative studies published between January 2000 and July 2020.

Subjects:

Caregivers of adults with kidney failure (estimated glomerular filtration rate < 15 mL/min/1.73 m²) managed conservatively.

Methods:

Data were extracted by 2 independent reviewers using a prespecified extraction tool. Study quality was assessed using the Critical Appraisal Skills Program (CASP) tool.

Measurements:

Descriptive reports of demographics, measurement scales, and outcomes. Thematic synthesis of qualitative data.

Results:

Six studies met inclusion criteria, including 3 quantitative and 3 descriptive qualitative studies. Caregivers of patients receiving conservative kidney management (CKM) experienced significant caregiver burden and similar impacts to their QOL as those caring for patients receiving dialysis. Thematic synthesis revealed 5 themes: Understanding the concept of CKM, Need for involvement in the decision for CKM, Identifying available supports, Uncertainty about the future and negotiating deteriorations and dying, and Burden of care impacting on QOL.

Limitations:

Low numbers of included studies, data collection and recruitment biases in qualitative studies and small caregiver numbers in quantitative studies, limit transferability of findings. Heterogeneity in study design and outcome measures precluded meta-analysis.

Conclusions:

Caregivers of patients with conservatively managed kidney failure suffer significant burden and experience QOL comparable with those caring for patients on dialysis. Limited understanding and involvement in conservative management decision making, and a fear of deterioration and dying, result in anxiety in caregivers. Further research into the experiences of caregivers will help support both caregivers and the patients who choose conservative management.

Registration:

PROSPERO registration number CRD42021209811.

Coexisting with the Life of Patients with Hemodialysis: Qualitative Meta-Synthesis Study of Life of Caregivers of Patients with Hemodialysis

As the number of patients with hemodialysis (HD) continues to increase, so too does the number of people depending on caregivers. There is need to pay attention to the lives of caregivers of patients with HD, where sacrifices are forced. This study systematically reviewed and synthesized qualitative studies that explored the experiences of caregivers caring for patients with HD using the meta-synthesis method. We searched literature using four databases (i.e., PubMed, Excerpta Medica dataBASE, Cumulated Index to Nursing and Allied Health Literature, and Web of Science), and finally ten publications were selected. Four themes and nine subtopics were derived from analyzing and synthesizing the research results. The synthesized themes were: “bearing the burden of life as a caregiver,” “reconstructing life to maintain hemodialysis”, “the fading of caregiver’s own life,” and “effort to relieve the burden.” The results of this study can contribute to the development of interventional studies to improve the quality of life of HD patients. These studies provide an integrated and in-depth perspective on the experiences of caregivers who care for HD patients.

The needs and well-being of severe asthma and COPD carers: A cross-sectional study

BACKGROUND AND OBJECTIVE

Caring for people with severe asthma and chronic obstructive pulmonary disease (COPD) can impair the quality of life (QoL) of the carer. We aimed to describe the QoL and needs of severe asthma and COPD carers.

METHODS

Carers of severe asthma (n = 89) and COPD (n = 48) completed an online cross-sectional survey assessing QoL and carer support needs using the Short Form Health Survey 12v2 (SF-12), the Hospital Anxiety and Depression Scale (HADS) and Carers Support Needs Assessment Tool (CSNAT) questionnaires.

RESULTS

Carers of people with severe asthma and COPD were similar in age (mean ± SD 57.78 ± 14.09 vs. 56.93 ± 12.91) and gender (65% female vs. 66%); however, they differed in caring duration (proportion caring for >10 years: 65% vs. 33%, p < 0.002). QoL was impaired in both groups, but there were no significant differences between severe asthma and COPD carers in either of the SF-12 component scores. The HADS scores revealed no difference between groups. Compared to severe asthma carers, COPD carers had significantly greater needs for: 'having time for self' (33% vs. 13%, p = 0.006), 'equipment to help care for relative' (33% vs. 13%, p = 0.006), 'practical help in the home' (35% vs. 18%, p = 0.006) and 'getting a break from caring overnight' (21% vs. 6%, p = 0.023).

CONCLUSION

QoL is impaired in carers of people with severe asthma to a similar degree of COPD carers and other debilitating diseases like cancer. These novel data highlight the support needs of severe asthma carers and identifies areas where tailored support is needed to reduce their substantial carer burden.

"It's like being on a roller coaster": the burden of caring for people with severe asthma

Introduction

Family carers and significant others play a fundamental role in the well-being of people with severe asthma. This study aimed to investigate the challenges faced by family carers/significant others of people with severe asthma, to understand if there is an unmet need and to explore coping strategies.

Methods

Carers of people with severe asthma were invited to participate in a face-to-face or telephone interview. Semi-structured interviews were conducted until reaching data saturation of themes. The 20 interviews were recorded and transcribed, and analysis of data followed an inductive thematic approach.

Results

We report three overarching emergent themes: 1) “Caring role impacts”, which centred around the negative and positive impacts of caring on carers' well-being; 2) “Unmet needs”, which encapsulated the support needs participants desired and were categorised into unmet information, biopsychosocial needs and carers' involvement in decision-making; and 3) “Coping strategies”, which were central to the range of tools and positive approaches in dealing with caring demands.

Discussion

Caring for someone with severe asthma can be burdensome and may negatively affect the physical and psychosocial health of the carer. Various coping strategies are used to manage the demands of these caring roles. Carers of people with severe asthma expressed a need for informational, biopsychosocial and involvement in care decision-making support. Tailored support services that are sensitive to their needs may improve their quality of life and encourage healthcare providers to value and acknowledge the important contribution that carers make.

Caring for someone with severe asthma can be burdensome, affecting the physical and psychosocial health of the supportive person negatively. Tailored support services may improve their quality of life.https://bit.ly/2KA9PWS

Development of a psychosocial intervention to support informal caregivers of people with end-stage kidney disease receiving haemodialysis

Background

Patients with end-stage kidney disease, receiving haemodialysis rely increasingly on informal carers to help manage their debilitating chronic disease. Informal carers may experience a negative impact on their quality of life exacting a toll on their physical, social and emotional well-being. Informal carers of patients with end-stage kidney disease receiving haemodialysis have significant unmet needs which may include physical and psychological issues, financial disadvantage and social isolation. Poor experiences of informal carers may also impact the experience of the patients for whom they care. The needs of this group of informal caregivers have been largely neglected, with little emphasis placed on supportive interventions that might assist and support them in their caring role. The aim of this study is therefore to explore the experiences and unmet needs of informal carers of people with end-stage kidney disease receiving haemodialysis and develop a psychosocial intervention to support them in their caring role.

Methods

This qualitative study will include a systematic review, semi-structured interviews with 30 informal carers and focus groups with renal health care professionals. Perceptions of care provision, caregiving experiences as well as contextual factors impacting the design and delivery of a psychosocial intervention for informal carers of patients with end-stage kidney disease, will be explored and will inform the development of a supportive intervention.

Discussion

The needs of informal carers of patients with end-stage kidney disease have been neglected with little emphasis placed on supportive interventions that might assist and support this group in their care giving role. This is in contrast to other chronic disease groups such as stroke, cancer and dementia. In these conditions well developed supportive interventions have significantly improved outcomes in regard to informal caregivers’ preparedness, competence, positive emotions and psychological well-being in terms of informal care provision. Support interventions could potentially improve the quality of life of those informal carers who provide care to patients with end-stage kidney disease receiving haemodialysis.

Perfil del cuidador del paciente con Enfermedad Renal Crónica: una revisión de la literatura

Introducción: Los cuidadores de pacientes con enfermedad renal crónica (ERC) presentan alteraciones físicas, sociales, económicas, espirituales y emocionales, derivadas de su rol. Conocer el perfil del cuidador principal es fundamental para establecer intervenciones de apoyo y asistencia. Objetivo: Determinar el perfil del cuidador del paciente con ERC referido en la literatura, que describa las variables sociodemográficas y el predominio de condiciones de salud relacionadas con el cuidado del familiar. Metodología: Se realizó una revisión narrativa de la literatura, siguiendo recomendaciones de la declaración PRISMA. Se incluyeron estudios primarios (experimentales u observacionales, cuantitativos y cualitativos), acerca de los efectos en la salud del cuidador familiar de pacientes. Se consultaron las bases de datos ProQuest, ScienceDirect, Scopus, Dialnet, Redalyc y Scielo; entre 2011 y 2018. Resultados: Como características sociodemográficas de los cuidadores familiares, predomina el 41.66 % mayor de 53 años; género femenino con 92.30%, estado civil: casados 66.66%; escolaridad primaria 26.08% y ocupación ama de casa 22.22%. En referencia a los efectos en salud, los emocionales prevalecen la ansiedad y depresión, seguido de alteraciones en el sueño, que afecta la calidad de vida del cuidador. Conclusión: El conocimiento del cuidador en sus variables sociodemográficas permite establecer acciones acordes a las necesidades y la intervención de efectos emocionales, mala calidad del sueño, el aislamiento social que afecta la calidad de vida del cuidador y por ende al paciente.

Valoración de la elección de tratamiento conservador en la enfermedad renal crónica

Introducción: El tratamiento conservador es una opción de tratamiento en la enfermedad renal crónica. Esta elección es decisión del paciente y/o familia. Objetivo: Analizar el proceso de elección de tratamiento conservador, identificar el perfil de paciente que lo elige, su supervivencia y quien comunica la elección. Material y Método: Estudio observacional, retrospectivo. Se incluyeron pacientes que eligieron tratamiento conservador entre 2010-2017. Los datos se obtuvieron de los registros de enfermería en historia clínica. Se recogieron variables demográficas, supervivencia, Índice de Comorbilidad de Charlson, índice de Barthel y valores de los pacientes utilizando la herramienta Tarjetas de valores. Resultados: Se estudiaron 95 pacientes: 41,05% hombres, edad media 82,36±9 años, 27,37% institucionalizados. La familia comunicó la elección en el 62,11% de los casos. La media del filtrado glomerular al inicio de la información fue 11,53±2,73ml/min, mediana del Charlson 8(13-3), Barthel 55 (100-0) puntos. En el proceso de evidenciar valores, la tarjeta más elegida fue “personal sanitario responsable del tratamiento”. La supervivencia media fue 496,19 días±553,8. Viven menos los hombres y los institucionalizados, sin diferencia significativa. El riesgo de muerte es mayor, al aumentar el Charlson y disminuir el filtrado glomerular (p=0,01). La familia comunicó la elección de seguir tratamiento conservador en el 62,11% de los casos. Conclusiones: El paciente que opta por tratamiento conservador es, una persona anciana, dependiente, con comorbilidades, supervivencia media en torno a 18 meses y en más de la mitad de los casos es la familia quien comunica la decisión de optar por ese tratamiento.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Barriers and facilitators influencing death at home: A meta-ethnography

BACKGROUND

In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach.

AIM

To identify and understand the barriers and facilitators influencing death at home.

DESIGN

Meta-ethnography.

DATA SOURCES

The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis.

RESULTS

A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication.

CONCLUSION

Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services.

End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'

BACKGROUND

Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions.

METHODS

A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK.

RESULTS

Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined.

CONCLUSIONS

The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.

Family caregiver's experiences of providing care to patients with End-Stage Renal Disease in South-West Nigeria

AIMS AND OBJECTIVES

To describe the experiences of family caregivers providing care for patients living with End-Stage Renal Disease in Nigeria BACKGROUND: Family caregiving is where an unpaid volunteer, usually a close family member, attends to the needs of a loved one with a chronic, disabling illness within the home. Much research has been conducted in the area of family caregiving in high-income countries. However, the same cannot be said for many of the low-resource, multicultural African countries.

DESIGN

Qualitative descriptive study.

METHOD

This qualitative descriptive study used manifest content analysis to analyse data from semi-structured, individual interviews, with 15 purposively selected family caregivers. Two tertiary institutions providing renal care in South-Western Nigeria: the research setting for this study.

RESULT

Five categories were identified, and these included disconnectedness with self and others, never-ending burden, 'a fool being tossed around', obligation to care and promoting a closer relationship.

CONCLUSION

Experiences associated with the caregiving of patients diagnosed with End-Stage Renal Disease evoked a number of emotions from the family caregivers, and the study revealed that caregiving imposed some burdens that are specific to low-resource countries on participants.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to engage family caregivers on disease-specific teachings that might promote understanding of the disease process and role expectation. Family caregivers may benefit from social support services.

Experiences and needs of older people with end stage renal disease: bereaved carers perspective

BACKGROUND

There is a growing population of older patients with End Stage Renal Disease (ESRD) managed without dialysis in Thailand, and services have yet to be developed to specifically respond to the needs of this group. As a consequence this population are likely to have unmet needs with respect to health care and suffer from symptoms that could be better managed.

OBJECTIVE

This qualitative study explored experiences and health care needs during the last year of life among older people with ESRD, managed without dialysis, from the perspective of bereaved carers.

METHODS

A retrospective post-bereavement approach was adopted to collect qualitative interview data. Purposive sampling was used to select 12 bereaved relatives of older patients with ESRD, managed without dialysis, who had died in the previous 5-10 months. Semi-structured interviews were conducted. Data were digitally recorded, transcribed and analysed through framework analysis.

RESULTS

Four main themes were identified: symptom experiences, impacts of being managed without dialysis, symptom management, and health care needs and utilisation of services.

CONCLUSIONS

Findings confirmed patients' needs were not being met and identified the need to develop approaches to symptom management at home, health education, and psychological and spiritual support at the end of life.

Spirituality in Renal Supportive Care: A Thematic Review

Chronic kidney disease is marked by a reduced life expectancy and a high symptom burden. For those who reach end-stage renal disease, the prognosis is poor, and this combined with the growing prevalence of the disease necessitates supportive and palliative care programmes that will address people's psychosocial, cultural and spiritual needs. While there is variation between countries, research reveals that many renal specialist nurses and doctors are reluctant to address spirituality, initiate end-of-life conversations or implement conservative treatment plans early. Yet, other studies indicate that the provision of palliative care services, which includes the spiritual dimension, can reduce symptom burden, assist patients in making advanced directives/plans and improve health-related quality of life. This review brings together the current literature related to renal supportive care and spirituality under the following sections and themes. The introduction and background sections situate spirituality in both healthcare generally and chronic kidney disease. Gaps in the provision of chronic kidney disease spiritual care are then considered, followed by a discussion of the palliative care model related to chronic kidney disease and spirituality. Chronic kidney disease spiritual needs and care approaches are discussed with reference to advanced care planning, hope, grief and relationships. A particular focus on quality of life is developed, with spirituality named as a key dimension. Finally, further challenges, such as culture, training and limitations, are explicated.

An appraisal of end-of-life care in persons with chronic kidney disease dying in hospital wards

AIM

To review end-of-life care provided by renal healthcare professionals to hospital in-patients with chronic kidney disease, and their carers, over a 12-month period in Northern Ireland.

METHODS

Retrospective review of 100 patients.

RESULTS

Mean age at death was 72 years (19-95) and 56% were male. Eighty three percent of patients had a 'Not For Attempted Resuscitation' order during their last admission and this was implemented in 42%. Less than 20% of all patients died in a hospital ward. No patients had an advanced care plan, although 42% had commenced the Liverpool Care Pathway for the Dying Patient. Patients suffered excessive end-of-life symptoms. In addition, there was limited documentation of carer involvement and carer needs were not formally assessed.

CONCLUSION

End-of-life care for patients with advanced chronic renal disease can be enhanced. There is significant variation in the recording of discussions regarding impending death and little preparation. There is poor recording of the patients' wishes regarding death. Those with declining functional status, including those frequently admitted to hospital require holistic assessment regarding end-of-life needs. More effective communication between the patient, family and multi-professional team is required for patients who are dying and those caring for them.

The challenge to health professionals when carers resist truth telling at the end of life: a qualitative secondary analysis

AIMS AND OBJECTIVES

To draw out the similar complexities faced by staff around truth-telling in a children's and adult population and to interrogate the dilemmas faced by staff when informal carers act to block truth-telling.

BACKGROUND

Policy encourages normalisation of death, but carers may act to protect or prevent the patient from being told the truth. Little is known about the impact on staff.

DESIGN

Secondary analysis of data using a supra-analysis design to identify commonality of experiences.

METHODS

Secondary 'supra-analysis' was used to transcend the focus of two primary studies in the UK, which examined staff perspectives in a palliative children's and a palliative adult setting, respectively. The analysis examined new theoretical questions relating to the commonality of issues independently derived in each primary study. Both primary studies used focus groups. Existing empirical data were analysed thematically and compared across the studies.

RESULTS

Staff reported a hiding of the truth by carers and sustained use of activities aimed at prolonging life. Carers frequently ignored the advance of end of life, and divergence between staff and carer approaches to truth-telling challenged professionals. Not being truthful with patients had a deleterious effect on staff, causing anger and feelings of incompetence.

CONCLUSIONS

Both children's and adult specialist palliative care staff found themselves caught in a dilemma, subject to policies that promoted openness in planning for death and informal carers who often prevented them from being truthful with patients about terminal prognosis. This dilemma had adverse psychological effects upon many staff.

RELEVANCE TO CLINICAL PRACTICE

There remains a powerful death-denying culture in many societies, and carers of dying patients may prevent staff from being truthful with their patients. The current situation is not ideal, and open discussion of this problem is the essential first step in finding a solution.

Exploring public awareness and perceptions of palliative care: a qualitative study

BACKGROUND

Research suggests that the public appear to be confused about the meaning of palliative care. Given the ageing population and associated increase in the number of patients requiring palliative care, it is vital to explore the public's understanding of this concept. Health-promoting palliative care seeks to translate hospice and palliative care ideals into broader public health practice.

AIM

To explore public perceptions of palliative care and identify strategies to raise awareness.

DESIGN

An exploratory qualitative approach.

PARTICIPANTS

Semi-structured telephone interviews were undertaken (N = 50) with members of the public who volunteered to participate in the study. The interviews focused on knowledge and perceptions of palliative care, expectations of palliative care services and the identification of strategies to raise public awareness of palliative care. The interviews were audio recorded and content analysed.

RESULTS

Most participants had a general knowledge of palliative care, largely influenced by their own personal experience. They identified that palliative care was about caring for people who were dying and maintaining comfort in the last days of life. Participant's expectations of services included the following: holistic support, symptom management, good communication and practical support to enable choice and carer support. Key aspects identified for promoting palliative care were the development of understanding and use of the term itself and targeted educational strategies.

CONCLUSION

Experience of palliative care generates understanding in the general public who also have ideas for increasing knowledge and awareness. The findings can inform policymakers about strategies to raise public awareness of palliative care.