Finding privacy from a public death: a qualitative exploration of how a dedicated space for end-of-life care in an acute hospital impacts on dying patients and their families

Utilization of End-of-Life Care Rooms by Patients Who Died in a Single Hospice Unit at a National University Hospital in South Korea

Purpose

For the dignity of patients nearing the end of their lives, it is essential to provide end-of-life (EoL) care in a separate, dedicated space. This study investigated the utilization of specialized rooms for dying patients within a hospice unit.

Methods

This retrospective study examined patients who died in a single hospice unit between January 1, 2017, and December 31, 2021. Utilizing medical records, we analyzed the circumstances surrounding death, the employment of specialized rooms for terminally ill patients, and the characteristics of those who received EoL care in a shared room.

Results

During the 1,825-day survey period, deaths occurred on 632 days, and 799 patients died. Of these patients, 496 (62.1%) received EoL care in a dedicated room. The average duration of using this dedicated space was 1.08 days. Meanwhile, 188 patients (23.5%) died in a shared room. Logistic regression analysis revealed that a longer stay in the hospice unit was associated with a lower risk of receiving EoL care in a shared room (odds ratio [OR]=0.98, 95% confidence interval [CI] 0.97~0.99; P=0.002). Furthermore, a higher number of deaths on the day a patient died was associated with a greater risk of receiving EoL care in a shared room (OR=1.66, 95% CI 1.33~2.08; P<0.001).

Conclusion

To ensure that more patients receive EoL care for an adequate duration in a private setting, additional research is necessary to increase the number of dedicated rooms and incorporate them into the hospice unit at an early stage.

Using Family Narrative Reports to Identify Practices for Improving End-of-Life Care Quality

CONTEXT

Patient experiences should be considered by healthcare systems when implementing care practices to improve quality of end-of-life care. Families and caregivers of recent in-patient decedents may be best positioned to recommend practices for quality improvement.

OBJECTIVES

To identify actionable practices that bereaved families highlight as contributing to high quality end-of-life care.

METHODS

We conducted qualitative content analysis of narrative responses to the Bereaved Family Surveys Veterans Health Administration inpatient decedents. Out of 5964 completed surveys in 2017, 4604 (77%) contained at least one word in response to the open-ended questions. For feasibility, 1500/4604 responses were randomly selected for analysis. An additional 300 randomly selected responses were analyzed to confirm saturation.

RESULTS

Over 23% percent (355/1500) of the initially analyzed narrative responses contained actionable practices. By synthesizing narrative responses to the BFS in a national healthcare system, we identified 98 actionable practices reported by the bereaved families that have potential for implementation in QI efforts. Specifically, we identified 67 end-of-life practices and 31 practices in patient-centered care domains of physical environment, food, staffing, coordination, technology and transportation. The 67 cluster into domains including respectful care and communication, emotional and spiritual support, death benefits, symptom management. Sorting these practices by target levels for organizational change illuminated opportunities for implementation.

CONCLUSION

Narrative responses from bereaved family members can yield approaches for systematic quality improvement. These approaches can serve as a menu in diverse contexts looking for approaches to improve patient quality of death in in-patient settings.

Facilitating family needs and support at the end of life in hospital: A descriptive study

BACKGROUND

Caring for family members of dying patients is a vital component of end-of-life care, yet family members' needs at the end of life may be unmet.

AIM

To explore hospital clinician assessment and facilitation of family needs and practices to support families at the end of life.

DESIGN

Descriptive study utilising a retrospective medical record audit.

SETTING AND SAMPLE

Undertaken in a large public hospital, the sample included 200 deceased patients from four specialities; general medicine (n = 50), intensive care (n = 50), inpatient palliative care (n = 50) and aged rehabilitation (n = 50). Data were analysed according to age; under 65-years and 65-years or over.

RESULTS

Deceased patients' mean age was 75-years, 60% were Christian and Next-of-Kin were documented in 96% of cases. 79% spoke English, yet interpreters were used in only 6% of cases. Formal family meetings were held in 64% of cases. An assessment of family needs was undertaken in 52% of cases, and more likely for those under 65-years (p = 0.027). Cultural/religious practices were supported/facilitated in only 6% of all cases. Specialist palliative care involvement was more likely for those aged 65-years or over (p = 0.040) and social work involvement more likely for those under 65-years (p = 0.002). Pastoral care and bereavement support was low across the whole sample.

CONCLUSIONS

Prioritising family needs should be core to end-of-life care. Anticipation of death should trigger routine referral to support personnel/services to ensure practice is guided by family needs. More research is needed to evaluate how family needs assessment can inform end-of-life care, supported by policy.

Experiences of surgical nurses in providing end-of-life care in an acute care setting: a qualitative study

BACKGROUND

The number of deaths occurring in hospitals is rising, and many occur in settings other than specialist palliative care, oncology or critical care. Nurses working outside these specialist environments report end-of-life (EoL) care as a source of stress. This research aimed to explore these experiences.

AIMS AND METHODS

This qualitative study, using semi-structured interviews as a research technique, aimed to investigate the experiences of surgical nurses caring for dying patients.

RESULTS

Five themes emerged: understanding of and preference for EoL care; perceived barriers while providing EoL care; robust support from the team as a facilitator while providing EoL care; symptom management; future training and support.

CONCLUSION

Participants considered providing EoL care as part of their professional role and reported that they were able to provide appropriate physical care. Participants identified challenges in providing emotional and psychological support to dying patients and their families in an acute surgical setting.

Smiles behind the masks: A systematic review and narrative synthesis exploring how family members of seriously ill or dying patients are supported during infectious disease outbreaks

BACKGROUND

Infection control measures during infectious disease outbreaks can have significant impacts on seriously ill and dying patients, their family, the patient-family connection, coping, grief and bereavement.

AIM

To explore how family members of patients who are seriously ill or who die during infectious disease outbreaks are supported and cared for during serious illness, before and after patient death and the factors that influence family presence around the time of death.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

CINAHL, Medline, APA PsycInfo and Embase were searched from inception to June 2020. Forward and backward searching of included papers were also undertaken. Records were independently assessed against inclusion criteria. Included papers were assessed for quality, but none were excluded.

FINDINGS

Key findings from 14 papers include the importance of communication and information sharing, as well as new ways of using virtual communication. Restrictive visiting practices were understood, but the impact of these restrictions on family experience cannot be underestimated, causing distress and suffering. Consistent advice and information were critical, such as explaining personal protective equipment, which family found constraining and staff experienced as affecting interpersonal communication. Cultural expectations of family caregiving were challenged during infectious disease outbreaks.

CONCLUSION

Learning from previous infectious disease outbreaks about how family are supported can be translated to the current COVID-19 pandemic and future infectious disease outbreaks. Consistent, culturally sensitive and tailored plans should be clearly communicated to family members, including when any restrictions may be amended or additional supports provided when someone is dying.

A conceptual analysis of the meaning of comfort at the end-of-life using the Walker and Avant (2014) Framework

Objective

The aim of the authors is to clarify the concept of comfort at the end-of-life in order to support understandings of fundamental nursing care needed at this stage of healthcare.

Methods

The Walker and Avant framework was applied to develop a deeper understanding of the concept of comfort at the end of life.

Results

Five defining attributes of comfort in the end-of-life were identified and they are having a peaceful home-life environment, trust and consolation, proximity and social-cultural support, alleviation of suffering, and a process of integrated intervention by nurses.

Conclusions

At the end-of-life patients commonly experience physical, psychological, social-cultural, and environmental discomfort. Patients’ families also encounter significant challenges. However, their comfort needs are often secondary to that of the patient. Additionally, a lack of clarity exists regarding the holistic meaning of comfort at the end-of-life, which can largely be confined to understandings of physical comfort for the patient, with a limited understanding of addressing family/caregivers’ needs. Therefore, this concept analysis may provide some guidance in this regard and also provides support toward a more integrated understanding of the concept.

The Physical Hospital Environment and Its Effects on Palliative Patients and Their Families: A Qualitative Meta-Synthesis

AIM

To review the latest qualitative literature on how the physical hospital environment affects palliative patients and their families.

BACKGROUND

People with a life-limiting illness may receive palliative care to improve their quality of life in hospital and may have multiple admissions as their illness progresses. Yet, despite a preference for a death at home, more than half of the dying population will receive end-of-life care in hospital. The physical hospital environment consists of ambiance, aesthetics, and architectural factors, and it is well known that the hospital's acute wards are not a homely environment. Demand is increasing for the physical environment to be improved to better meet the needs and demands of palliative and end-of-life patients and their families.

METHOD

Combining thematic analysis and meta-ethnography methodologies, 12 international qualitative papers were analyzed and synthesized by the three authors.

RESULTS

Findings resulted in the development of the SSAFeR Place approach that incorporates the concepts that are important to palliative and end-of-life patients and their families by describing an environment within the acute or palliative care units that feels safe, is private, customizable, and accommodates family; is a space to share with others, is homelike in ambiance and aesthetics, and is conducive for reflection. The concepts of identity, belonging, and safety are connected to the notions of home.

CONCLUSIONS

To provide person-centered care and to move the focus toward the palliative approach of comfort and quality of life, attention to room size, layout, aesthetics, and ambiance is needed.

Structure and process of palliative care provision: a nationwide study of public hospitals in Thailand

Background

The demand for palliative care in hospitals in Thailand has rapidly increased in recent years. Subsequently, the way in which palliative care systems should be arranged to facilitate the care process and patient preparation for their end stage of life is still an ongoing debate among policy makers and researchers. Although palliative care is provided in most facilities, there is no clear protocol for palliative care due to a lack of empirical evidence. Thus, this study attempts to analyse the situation and quality of palliative care provision in Thai public hospitals.

Methods

A cross-sectional study was conducted in 2018. A questionnaire with measures concerning hospital characteristics, the structure of palliative care provision, and processes related to achieving a good death was developed. The questionnaire was sent to all 862 public hospitals across 76 provinces, and the response rate was 62.88%. A structural equation model was specified to operationalize Donabedian’s framework. To our knowledge, this is the first nationwide study to investigate facility-level palliative care provision in Thailand.

Results

The study results confirmed the relationships between the structure and process of palliative care provision in hospitals. The sufficiency and competency of doctors and nurses and the variety of relaxation equipment were either directly or indirectly associated with the process components relevant to the response to the patient’s needs, effective communication, and respect for the patient’s dignity. In addition, the performance of palliative care research in hospitals was associated with the response to the patient’s needs and effective communication, while the allocation of physical areas was associated with effective communication.

Conclusion

This model can be used to evaluate the overall situation of palliative care provision at the national level. It could also contribute to the development of standard measurements for evidence-based palliative care quality improvement in hospitals.

Perceptions of Palliative Care Nurses Related to Death and Palliative Care Practices

This study has been conducted with the purpose of identifying the perceptions of palliative nurses about death and determining palliative care practices. We conducted qualitative interviews with 23 palliative care nurses in Turkey. Content analysis was used in the evaluation of the data. Three themes have been identified about perception of death. Furthermore, three themes have been identified about palliative care practices. It was concluded that the palliative nurses perceive death as a natural and inevitable process and that as long as their working period increases, they become desensitized. It was identified that the participants generally perform the following procedures in palliative care practices.

Social Work Practice with Medical Assistance in Dying: A Case Study

Medical assistance in dying (MAiD) recently became legal in Canada, and social workers have an integral role providing psychosocial care to those considering this end-of-life care option. Research has found that most requests for assisted dying have a psychosocial dimension. Social workers are uniquely equipped to understand the personal and contextual factors informing the choice for MAiD and offer supports. A case example highlights practice opportunities for social workers throughout the MAiD process.

Family members´ experiences of the end-of-life care environments in acute care settings - a photo-elicitation study

PURPOSE

This article explores experiences of the acute-care environment as a setting for end-of-life (EoL) care from the perspective of family members of a dying person.

METHOD

We used participant-produced photographs in conjunction with follow-up interviews with nine family members to persons at the EoL, cared for in two acute-care settings.

RESULTS

The interpretive description analysis process resulted in three constructed themes-Aesthetic and un-aesthetic impressions, Space for privacy and social relationships, and Need for guidance in crucial times. Aspects of importance in the physical setting related to aesthetics, particularly in regard to sensory experience, and to a need for enough privacy to facilitate the maintenance of social relationships. Interactions between the world of family members and that of professionals were described as intrinsically related to guidance about both the material and immaterial environment at crucial times.

CONCLUSION

The care environment, already recognized to have an impact in relation to patients, is concluded to also affect the participating family members in this study in a variety of ways.

Registered nurses' provision of end-of-life care to hospitalised adults: A mixed studies review

OBJECTIVES

To describe, critically appraise and synthesise research regarding nurses' perceptions of their knowledge, skills or experiences in providing end-of-life care to hospitalised adults to help inform both future educational and practice initiatives.

DESIGN

Mixed studies review.

DATA SOURCES

MEDLINE, CINAHL, Cochrane Library, Web of Science and SCOPUS databases were searched for the years 2004-June 2018, along with journal hand-searching and reference list searching.

REVIEW METHODS

Two independent reviewers screened the titles and abstracts of studies. Data extraction and quality assessment using the Mixed Methods Appraisal Tool was conducted independently by two reviewers. Disagreements were adjudicated by a third reviewer. Study findings were synthesised thematically.

RESULTS

Nineteen studies met the inclusion criteria. Of them, ten were quantitative, eight qualitative and one mixed-method. All but one quantitative study were conducted in the United States and all but one used some form of survey. The qualitative studies were conducted in a variety of countries and all but one used some form of interview for data collection. Five themes were identified including nurse as a protecting provider, nurse as an advocate, nurse as a reflective practitioner, obstacles to providing quality end-of-life care and aids to providing quality end-of-life care.

CONCLUSIONS

Registered Nurses have aligned their end-of-life care with practice with the profession's expectations and are enacting a patient centred approach to their practice. They rely on reflective practices and on the support of others to overcome organisational, educational and emotional the challenges they to providing quality end-of-life care.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

Background

End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.

Methods

This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.

Results

Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.

Conclusions

Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

Comfort-Supporting Nursing Activities for End-of-Life Patients in an Institutionalized Environment

PURPOSE

Comfort promotion plays a significant role in end-of-life patient care. The objective of this study was to determine the utilization rate of comfort supporting nursing activities in end-of-life patients in an institutionalized environment in the Czech Republic in relation to the age of the registered nurses (RNs), length of work experience, education level, and type of workplace.

DESIGN

A cross-sectional, descriptive study was designed. A questionnaire with Likert scales included 31 activities of dying care and spiritual support interventions. The sample comprised 907 RNs working in 49 institutions in nine regions of the Czech Republic. The Kruskal-Wallis test, Mann-Whitney U post-hoc test with Bonferroni correction of significance, Spearman's correlation analysis, and logical regression model were used for statistical evaluation.

FINDINGS

The least frequently implemented activity by RNs was "Show the patient's willingness to discuss death" and the most frequent activity was "Threat to the patient's dignity and respect." The highest utilization rate of nursing activities was reported in the physical dimension, while the lowest utilization rate of nursing activities was in the social dimension set. Significant predictors for the high utilization rate of physical dimension set activities were hospice care departments, long-term care facilities (LTCFs), and the age of RNs. Hospice departments were also a predictor of high utilization rate of activities in the psychological, spiritual, and social dimension set activities.

CONCLUSIONS

With the exception of hospice departments, RNs used activities encouraging psychological, spiritual, and social comfort for end-of-life patients less frequently than the physical dimension.

CLINICAL RELEVANCE

RNs in hospitals and LTCFs focus insufficiently on the spiritual and psychosocial comfort of end-of-life patients. This study is of particular significance to educators who prepare the next generation of nurses.