Dignity in end-of-life care at hospice: An Action Research Study

Dignity in people with dementia: A concept analysis

Background: Dignity, an abstract and complex concept, is an essential part of humanity and an underlying guiding principle in healthcare. Previous literature indicates dignity is compromised in people with dementia (PwD), but those PwD maintain the capacity to live with dignity with appropriate external support. Alzheimer's disease and related dementias (ADRDs) lead to progressive functional decline and increased vulnerability and dependence, leading to heightened risks of PwD receiving inappropriate or insufficient care that diminishes dignity. Considering the increased disease prevalence and the continuously escalating costs of dementia care, establishing a productive value-based guideline may prevent suffering, maximize dignity, and thus promote quality of life (QoL).Aim: The goal of this project is to identify actionable targets for integrating dignity harmoniously and practically into care planning and management for PwD.Research Design: We conducted a concept analysis using Walker and Avant's eight-step process. A comprehensive literature search was conducted (PubMed and CINAHL) with the keywords "dignity," "dementia," "Alzheimer's disease," and "dementia care."Results: A total of 42 out of 4910 publications were included. The concept of dignity in PwD is operationalized as the promotion of worthiness and the accordance of respect that allows the presence and expression of a person's sense of self, regardless of physical, mental, or cognitive health. The concept has two subdimensions: absolute dignity which encompasses the inherent self and relative dignity characterized by its dynamic reflective nature. Worthiness and respect are the two main attributes, while autonomy is an underlying component of dignity. Specific antecedents of dignity in PwD are empowerment, non-maleficence, and adaptive environmental scaffolding. As a consequence of facilitating dignity in PwD, QoL may be enhanced.Conclusion: As a foundational and necessary humanistic value, incorporating dignity into dementia care can lead to efficient and effective care that optimizes QoL in PwD throughout their disease progression.

Hospice Satisfaction Among Patients, Family, and Caregivers: A Systematic Review of the Literature

Background: Hospice care is an underused form of intervention at the end of life. The experiences of patients, families, and other caregivers are important to consider in thinking about how to encourage greater use of hospice care, through policies and advocacy that promote its benefits. Specifically, patient, family, and other caregiver satisfaction with hospice care is important to understand better. Methods: A PRISMA-guided review of the research on hospice care satisfaction and its correlates among patients, families, and other caregivers. Included in the review is research published over the time period 2000-2023 identifying a hospice care satisfaction finding. Results: Thirty-eight studies were included in the review. Key findings were: (a) higher levels of hospice care satisfaction among patients, families, and other caregivers; and (b) correlates of hospice care satisfaction falling into the categories of communication, comfort, and support. The published literature had fewer findings related to demographic correlates of satisfaction such as age or race/ethnicity and was lacking in comparative research examining satisfaction across different types of hospice care settings. Discussion: Extant research demonstrates a consistently higher level of hospice care satisfaction among patients, families, and other caregivers. This satisfaction appears related to specific aspects of care delivery that involve effective care coordination and communication; pain and symptom management; and emotional support. Strengthening future research involves testing additional interventions aimed at enhancing satisfaction; including more comparative research across hospice care settings; and more studies that include patients as the key respondents.

End-of-life conversations for the older person: A concept analysis

AIM

The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person.

DESIGN

Walker and Avant's eight step approach to Concept Analysis.

DATA SOURCES

Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis.

RESULTS

The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner.

CONCLUSIONS

End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.

Effectiveness of dignity therapy on well-being among patients under palliative care: A systematic review and meta-analysis

BACKGROUND

Dignity therapy is a psychotherapeutic intervention that is potentially effective in improving the well-being of patients receiving palliative care. However, the effects of dignity therapy are not well-understood.

OBJECTIVE

We attempted to determine the effectiveness of dignity therapy in palliative patients to provide evidence that dignity therapy could be used in their care.

DESIGN

Systematic review.

PARTICIPANTS

The number of participants from all the studies was 1202 (intervention group, 619 patients; control group, 583 patients).

METHODS

The review was reported according to the updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. Relevant studies were collected with database searching of PubMed, Scopus, ScienceDirect, ProQuest Health & Medical Complete, CINAHL, and Psych Info databases from the inception of dignity therapy in 2002 to 2022. Literature was selected to identify trials of dignity therapy in patients with palliative care needs including cancer and non-cancer condition. Critical appraisal was performed independently by two reviewers to assess the relevance, reliability, and quality of the included studies. Two independent reviewers extracted data from all the studies. Data were synthesized using Review Manager version 4.5.

RESULTS

A total of 16 studies involving 1202 participants were included. Most studies were rated as medium quality (n = 10, 62.5 %). The results showed a significant difference between the dignity and control groups in dignity-related distress (MD = -3.54, 95 % CI: [-4.66, -2.42], p < 0.00001), hope (MD = 2.27, 95 % CI: [1.32, 3.22], p < 0.0001), and quality of life (SMD = 0.45, 95 % CI: [0.15, 1.14], p = 0.00). However, no significant difference was observed in depression (MD = -0.44, 95 % CI: [-1.09, 0.20], p = 0.18); anxiety (MD = -0.21, 95 % CI: [-1.68, 1.27], p = 0.78), and spiritual well-being (MD = 2.41, 95 % CI: [-0.82, 5.64], p = 0.14).

CONCLUSIONS

Dignity therapy was effective in improving dignity-related distress, quality of life, and levels of hope. A meta-analysis found no significant differences in patients' psychological or spiritual well-being. Differences in the providers of dignity therapy in the included studies may be the cause of the different findings regarding the varying effects of dignity therapy. Professional health workers need to be trained as dignity therapists to enhance the visibility of dignity therapy for patients.

REGISTRATION

CRD42022375319.

TWEETABLE ABSTRACT

Dignity therapy is an effective and promising intervention in palliative care.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Existential aspects of parenthood transition seen from the health professionals' perspective - an interview and theatre workshop study

OBJECTIVES

A sense of existential vulnerability is embedded in parenthood transition. It is linked to meaning in life, relationship changes, awareness of death, and sometimes a transcendent belief. Nevertheless, in most maternity service guidelines, the existential aspects of life are not an explicit focus. Therefore, this study aimed to explore how health professionals in maternity services experience and understand existential aspects of parenthood transition among new parents.

STUDY DESIGN

Data were generated through a user-involving two-phase process inspired by action research consisting of three focus group interviews with health professionals (n = 10) and, subsequently, a theatre workshop for parents, health professionals, and researchers (n = 40). Between the two phases, case narratives were constructed using information from the interviews and, in collaboration with a dramatist, dramatized and then played out at a workshop by professional actors. We used thematic analysis for all data.

RESULTS

We identified five themes in the data material: 1. Death and fragility in maternity care, 2. Existential aspects in camouflage, 3. Existential and spiritual aspects of being professional in maternity care, 4. Talking about existential aspects of care, 5. Equipped for providing existential care?

CONCLUSIONS

Existential aspects were often recognized during birth, specially in traumatic situations or discerned in the physical and non-verbal relational energy between the birthing woman and midwife or partner. Less often, existential aspects were recognized during pregnancy and the post-partum period.

Caring Spiritually: A Study on Spiritual Care Training in a Hospice Setting

Spiritual care can improve patients' physical and emotional well-being, but patients at the end of life often experience their spiritual needs are not being sufficiently met by the health care professionals. This is caused by barriers among health care professionals that stem from inadequate education on spiritual care and lack of self-reflection on spiritual topics. By participating in spiritual care training, health care professionals seem to gain the knowledge, confidence, and skills they need to care spiritually for patients. The aim of this study was to evaluate the effect and experiences of a training course in spiritual care for 30 nurses working at a Danish hospice. This was done by means of both a before-and-after questionnaire and focus group interviews. The course focused primarily on the nurses and their personal and collegial reflections on spiritual care, whereas increased spiritual care for patients seemed to be a secondary outcome of the course. There was a significant statistical correlation between the nurses' values and spirituality, and their confidence in being able to exercise spiritual care for patients. The training course facilitated spiritual empowerment, collegial spiritual care, and spiritual language among the nurses, which led to increased spiritual care for patients.

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

Dignity in bodily care at the end of life in a nursing home: an ethnographic study

Background

Nursing homes (NHs) are populated by the frailest older people who have multiple physical or mental conditions and palliative care needs that may convey the violation of dignity. Although dignity is a commonly used concept and a core value of end-of-life care, it is assumed to be complex, ambiguous, and multivalent. Thus, the aim of this study was to explore aspects of dignity in older persons’ everyday lives in a NH.

Design

A focused ethnographic study design.

Methods

Data consisted of 170 h of fieldwork, including observations (n = 39) with residents (n = 19) and assistant nurses (n = 22) in a Swedish NH. Interviews were undertaken with residents several times (in total, n = 35, mean 70 min/resident). To study dignity and dignity-related concerns, we used the Chochinov model of dignity to direct the deductive analysis.

Results

The study showed that residents suffered from illness-related concerns that inhibited their possibilities to live a dignified life at the NH. Their failing bodies were the most significant threat to their dignity, as loss of abilities was constantly progressing. Together with a fear of becoming more dependent, this caused feelings of agony, loneliness, and meaninglessness. The most dignity-conserving repertoire came from within themselves. Their self-knowledge had provided them with tools to distinguish what was still possible from what they just had to accept. Socially, the residents’ dignity depended on assistant nurses’ routines and behaviour. Their dignity was violated by long waiting times, lack of integrity in care, deteriorating routines, and also by distanced and sometimes harsh encounters with assistant nurses. Because the residents cherished autonomy and self-determination, while still needing much help, these circumstances placed them in a vulnerable situation.

Conclusions

According to residents’ narratives, important dignity-conserving abilities came from within themselves. Dignity-conserving interventions did occur, such as emphatic listening and bodily care, performed in respect for residents’ preferences. However, no strategies for future crises or preparing for death were observed. To protect residents’ dignity, NHs must apply a palliative care approach to provide holistic care that comprises attention to personal, bodily, social, spiritual, and psychological needs to increase well-being and prevent suffering.

Dignity at the end of life: from philosophy to health care practice - Lithuanian case

Regulation and clinical practices regarding end of human life care differ among the nations and countries. These differences reflect the history of the development of state health systems, different societal values, and different understandings of dignity and what it means to protect or respect dignity. The result is variation in the ethical, legal, and practical approaches to end-of-life issues. The article analyzes the diversity of strategies to strengthen dignity at the end of life of terminally ill patients and to highlight the legal preconditions and limitations for implementing these strategies in independent Lithuania, as a former state of the Soviet Union. It is based on the critical analysis of philosophical literature, legal national and international documents and scientific evidence related to the issue. The author argues that the legal system in Lithuania is not sufficient to ensure the patient's dignity at the end of life and remains far behind other Western European countries. Legal regulations in Lithuania do not guarantee the right of the patient to express his or her will regarding the future treatment, including the refusal of resuscitation, do not regulate the termination of burdensome, non-viable and meaningless treatment that is undesired by the patient, and limit the accessibility of palliative care with its necessary quality and comfort.

A Consensus Definition of End of Life from an International and Interdisciplinary Perspective: A Delphi Panel Study

Background: Those working in the field of palliative care have recognized that many terms are being used synonymously and that clear definitions (or any definitions) for many of these terms are lacking. The synonymous use of the terms palliative and end of life (EOL) can especially lead to conflicts in clinical practice, such as a tardy referral to palliative care. Such conflicts may then result in poorer treatment of patients, for instance, pain management. In research, the lack of clear definitions or even of any established definition for central concepts, such as EOL, weakens study validity and research outcomes. Objective: The aim of this study was to establish a concise definition for the EOL phase. Design: A modified Delphi study design was chosen. A structured questionnaire based on a previously conducted concept analysis about the EOL was used. Setting: A panel of international and interdisciplinary experts was established. Between 34 (1st round) and 21 (4th round) individuals participated in the anonymous online expert panel. Results: After four panel rounds, we were able to provide a definition which covers physical and psychosocial aspects that should be considered at the beginning of the EOL phase and possible predictions about the remaining time. The definition also covers aspects of EOL care, such as considerations related to the individual's dignity, spirituality, and maintenance of relationships. Conclusion: EOL is a term which is defined by considering multiple aspects that affect the process of identifying the EOL phase, the EOL phase itself and the resulting care options.

A systematic scoping review on patients' perceptions of dignity

Background

A socioculturally appropriate appreciation of dignity is pivotal to the effective provision of care for dying patients. Yet concepts of dignity remain poorly defined. To address this gap in understanding and enhance dignity conserving end-of-life care, a review of current concepts of dignity is proposed.

Methods

To address its primary research question “How do patients conceive the concept of dignity at the end of life?”, this review appraises regnant concepts and influences of dignity, and evaluates current dignity conserving practices. To enhance accountability, transparency and reproducibility, this review employs the Ring Theory of Personhood (RToP) as its theoretical lens to guide a Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) of patient perspectives of dignity. Three independent teams of reviewers independently analysed included articles from a structured search of PubMed, Embase, PsycINFO, Scopus, CINAHL and Cochrane Databases using thematic and content analyses. The themes and categories identified were compared and combined using the Funnelling Process to create domains that guide the discussion that follows.

Results

Seventy-eight thousand five hundred seventy-five abstracts were identified, 645 articles were reviewed, and 127 articles were included. The three domains identified were definitions of dignity, influences upon perceptions of dignity, and dignity conserving care.

Conclusions

This SSR in SEBA affirms the notion that dignity is intimately entwined with self-concepts of personhood and that effective dignity conserving measures at the end of life must be guided by the patient’s concept of dignity. This SSR in SEBA posits that such personalised culturally sensitive, and timely support of patients, their family and loved ones may be possible through the early and longitudinal application of a RToP based tool.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01004-4.

Four aspects of spiritual care: a phenomenological action research study on practicing and improving spiritual care at two Danish hospices

BACKGROUND

In Denmark and internationally, there has been an increased focus on strengthening palliative care by enhancing spiritual care. Dying patients, however, do not experience their spiritual needs being adequately met.

METHODS

Through an action research study design with four consecutive stages, namely, observation in practice, reflection-on-praxis, action-in-praxis, and evaluation of the action research process involving patients and hospice staff from two hospices in Denmark, two research questions were explored: (1) How do patients and staff perceive, feel, live, practice, and understand spiritual care at hospice? and (2) How can spiritual care be improved in hospice practice? The data material presented comprised 12 individual interviews with patients and nine focus group interviews with the staff.

RESULTS

We found four aspects of spiritual care through which patients and staff seemed to perceive, feel, live, practice, and understand spiritual care at hospice, and from where spiritual care may be improved in hospice practice. These aspects constituted four themes: (1) relational, (2) individualistic, (3) embodied, and (4) verbal aspects of spiritual care.

CONCLUSION

Staff realized immanent limitations of individual aspects of spiritual care but learned to trust that their relational abilities could improve spiritual care. Embodied aspects seemed to open for verbal aspects of spiritual care, but staff were reluctant to initiative verbal dialogue. They would bodily sense values about preserving patients' boundaries in ways that seemed to hinder verbal aspects of spiritual care. During action-in-praxis, however, staff realized that they might have to initiate spiritual conversation in order to care for patients' spiritual needs.

Developing an Educational Course in Spiritual Care: An Action Research Study at Two Danish Hospices

Further improvement of spiritual care in palliative care is warranted. Particularly reducing barriers and enhancing spiritual care competencies among the healthcare professionals is needed. The aim was to develop a training course in spiritual care in close collaboration with patients and staff from two Danish hospices. We applied an action research design to ensure that the training course was rooted in everyday practice of patients and staff. The methodology applied was based on philosophical hermeneutics and existential phenomenology. The action research process enabled the division into three topics on how a training course can reduce barriers towards spiritual care among the healthcare professionals. These three topics functioned as a theoretical framework for educating staff at a hospice in spiritual care. The three topics were: (1) the vulnerable encounter; (2) self-reflection concerning spiritual needs, thoughts, beliefs, and values; and (3) shared professional language for spiritual care. We operationalized the three topics into a flexible course design that could be adaptable to the practical possibilities and limitations of the individual hospice. The curriculum includes theoretical teaching, reflection exercises, and an improvisation theater workshop with professional actors. Educating staff led to the improvement of spiritual care at the hospices involved in the study.

Learning to care for the spirit of dying patients: the impact of spiritual care training in a hospice-setting

Background

Patients approaching the end of their life do not experience their existential and spiritual needs being sufficiently met by the healthcare professionals responsible for their care. Research suggest that this is partly due to a lack of insight about spiritual care among healthcare professionals. By developing, implementing, and evaluating a research-based educational course on spiritual care targeting hospice staff, we aimed to explore the perceived barriers for providing spiritual care within a hospice setting and to evaluate the post-course impact among staff members.

Methods

Course development and evaluation was based on primary exploratory action research and followed the UK Medical Research Council’s framework for complex intervention research. The course was implemented at two Danish hospices and comprised thematic days that included lectures, reflective exercises and improvised participatory theatre. We investigated the course impact using a questionnaire and focus group interviews. The questionnaire data were summarized in bar charts and analysis of the transcribed interviews was performed based on Interpretative Phenomenological Analysis.

Results

85 staff members participated in the course. Of these, 57 answered the evaluative questionnaire and 15 participated in 5 focus group interviews.

The course elements that the participants reported to be the most relevant were improvised theatre unfolding existential themes and reflexive group activities. 98% of participants found the course relevant, answering either “relevant” or “very relevant”. 73,1% of participants answered “to a considerable extent” or “to a great extent” when asked to what extent they assessed the content of the course to influence their work in hospice.

The focus group data resulted in 3 overall themes regarding perceived barriers for providing spiritual care: 1. Diverse approaches is beneficial for spiritual care, but the lack of a shared and adequate spiritual language is a communicative barrier, 2. Existential conversation is complicated by patients’ overlapping physical and existential needs, as well as miscommunication, and 3. Providing spiritual care requires spiritual self-reflection, self-awareness, introspection, and vulnerability.

Conclusions

This study provides insights into the barriers facing spiritual care in a hospice setting. Furthermore, the course evaluations demonstrate the valuable impact of spiritual care training for health care professionals. Further course work development is warranted to enhance the “science” of spiritual care for the dying.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00804-4.