The role and significance of nurses in managing transitions to palliative care: a qualitative study

Palliative Care and Hospice for Heart Failure Patients: Position Statement From the Korean Society of Heart Failure

Heart failure (HF) is a major cause of mortality and morbidity in South Korea, imposing substantial physical, emotional, and financial burdens on patients and society. Despite the high burden of symptom and complex care needs of HF patients, palliative care and hospice services remain underutilized in South Korea due to cultural, institutional, and knowledge-related barriers. This position statement from the Korean Society of Heart Failure emphasizes the need for integrating palliative and hospice care into HF management to improve quality of life and support holistic care for patients and their families. By clarifying the role of palliative care in HF and proposing practical referral criteria, this position statement aims to bridge the gap between HF and palliative care services in South Korea, ultimately improving patient-centered outcomes and aligning treatment with the goals and values of HF patients.

Emergency care experiences of patients known to palliative care services and their family: A qualitative interview study

BACKGROUND

With aging and comorbid populations and healthcare services under pressure, emergency department presentations related to palliative care needs are increasing. Little is known about patient and family experiences of care in this context. This study explores the emergency department care experiences of palliative patients and their family members.

METHODS

Semi-structured interviews with patients known to palliative care services who had presented to an urban emergency department within the study recruitment period. Six patients and five family members were interviewed. Reflexive thematic analysis methodology was underpinned by social constructivism.

FINDINGS

Participants often described misalignment between emergency care priorities and their own, which was sometimes associated with challenges, including dehumanisation. However, participants also shared stories of supported self-advocacy, associated with positive care experiences.

CONCLUSION

This research identifies challenges patients and their family experience when accessing emergency department care. Symptom management, time, environment, and advocacy were impactful aspects of patient and family experience. There is a need to develop and support palliative care skills and knowledge within EDs, and adapt the environment to provide a safe space for sensitive communication and person-centred care.

Referrals to Palliative Care Services for Hospitalised COVID-19 Patients: A Systematic Literature Review

BACKGROUND

The increase in the incidence of the coronavirus disease 2019 (COVID-19) led to more hospital admissions and deaths, and coincided with an increased need for palliative care. The new circumstances required palliative care services to be flexible and to develop response strategies.

AIM

To synthesise studies including COVID-19 patients to gain insight into how many patients were referred to hospital-based palliative care services, the characteristics and palliative care needs of these patients and the reasons for referral.

DESIGN

A systematic literature search was conducted in January 2022 using the PubMed, Embase, CINAHL, and PsycInfo databases.

RESULTS

Twenty-seven studies were identified. The results show that in 16% of all COVID-19 inpatients and 55% of all deceased COVID-19 inpatients were referred to a palliative care service. The median time from hospital admission to referral was 4 days and from referral to death was 2 days. COVID-19 inpatients were frequently referred for end-of-life care management (52%), had ≥1 comorbidities (84%), and suffered from shortness of breath/dyspnea (45%).

CONCLUSIONS

The care provided was generally acute, with a high proportion of end-of-life care referrals and a short time period from hospital admission to referral and from referral to death. This highlights the importance of early integration of palliative care into emergency department (ED) care of critically ill patients.

Nurses' Subjectivity in Patient-Centered Communication for End-of-Life Patients

Effective patient-centered communication is essential in providing quality care for patients at the end of life. This study aimed to explore the subjectivity of nurses' communication approaches using Q methodology. In this study, 33 Q-samples were constructed based on in-depth interviews with 12 hospice nurses. The Q classification was performed by a total of 38 hospice nurses who had more than 3 years of experience in hospice settings. The collected data were analyzed through the principal component analysis method and the varimax rotation process using the PQ method program. As a result, a total of 4 distinct types emerged: "sincere listener," "family-centered caregiver," "resource utilization facilitator," and "sufficient time devoter." The factors accounted for 64% of the variance: 19%, 15%, 16%, and 14% respectively. By identifying distinct viewpoints, valuable insights into the diverse perspectives held by nurses in patient-centered communication were gained. Understanding these viewpoints will contribute to the development of tailored communication strategies and training programs. In addition, the study underscores the need for training, resources, and organizational support to enhance nurses' communication skills.

Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review

Purpose

Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State.

Methods

A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed.

Results

Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths.

Conclusion

We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07364-0.

Adolescent on the bridge: Transitioning adolescents living with HIV to an adult clinic, in Ghana, to go or not to go?

Background

Children survive into adult life with Human Immunodeficiency Virus (HIV), which previously would have been lethal in early childhood.

Methods

The study aimed to describe the current transitional process for Adolescents Living with HIV (ALHIV) in a resource-limited setting in Ashanti Region, Ghana. The study was an explorative study that used an interpretive paradigm. A semi-structured interview guide was used to interview ALHIV, selected by purposive sampling. The study was conducted at a tertiary hospital in Kumasi. Data were analysed using thematic analysis.

Results

Transitioning of ALHIV was done without any guide; the themes generated were on the process of transition in which they used age (13 and above) and disclosure as the criterion to move ALHIV to the adult clinic. Most adolescents complained about being stigmatised, the attitude of staff, interruption of school and separation anxiety as experiences they went through during the transitioning process. On improving transition, ALHIV felt sexual and reproductive health services, information on treatment, privacy, and support were necessary transition components.

Conclusion

The use of age and disclosure of status as a criterion for transitioning ALHIV affects moving and retaining this age group in HIV management programs in the adult clinics. There is, therefore, an urgent need for a guideline as the current transition process defeats the purpose of providing adolescents with age-specific care in the Adult Clinic.

Comparing Perceptions, Determinants, and Needs of Patients, Family Members, Nurses, and Physicians When Making Life-Sustaining Treatment Decisions for Patients with Hematologic Malignancies

Purpose

This descriptive study compared the perceptions, determinants, and needs of patients, family members, nurses, and physicians regarding life-sustaining treatment decisions for patients with hematologic malignancies in the hematology-oncology department of a tertiary hospital in Seoul, Korea.

Methods

In total, 147 subjects were recruited, gave written consent, and provided data by completing a structured questionnaire. Data were analyzed using analysis of variance, the chi-square test, and the Fisher exact test.

Results

Nurses (F=3.35) and physicians (F=3.57) showed significantly greater familiarity with the Act on Decisions on Life-Sustaining Treatment than patients (F=2.69) and family members (F=2.59); (F=19.58, P<0.001). Many respondents, including 19 (51.4%) family members, 16 (43.2%) physicians, and 11 (29.7%) nurses, agreed that the patient's opinion had the greatest effect when making life-sustaining treatment decisions. Twelve (33.3%) patients answered that mental, physical, and financial burdens were the most important factors in life-sustaining treatment decisions, and there was a significant difference among the four groups (P<0.001). Twenty-four patients (66.7%), 27 (73.0%) family members, and 21(56.8%) nurses answered that physicians were the most appropriate people to provide information regarding life-sustaining treatment decisions. Unexpectedly, 19 (51.4%) physicians answered that hospice nurse practitioners were the most appropriate people to talk to about life-sustaining treatment (P<0.001).

Conclusion

It is of utmost importance that the patient and physician determine when life-sustaining treatment should be withdrawn, with the patient making the ultimate decision. Doctors and nurses have the responsibility to provide detailed information. The goal of end-of-life planning is to ensure patients' dignity and respect their values.

Early Palliative Care for Oncology Patients: How APRNs Can Take the Lead

BACKGROUND

Patients with cancer need expert and multidisciplinary care throughout the trajectory of their illness. Palliative care should be instituted early in the course of their disease. Early palliative care enables patients and their families to control physical, psychological, social, and spiritual symptoms of the disease. In our current health-care system, early palliative care is not being integrated due to a lack of education of providers and nurses, an infrastructure that does not support palliative medicine, and poor communication skills among practitioners.

METHODS AND RESULTS

The Palliative Care Quiz for Nursing (PCQN) completed by nurse practitioners at a large Midwest cancer center found that those nurse practitioners had a poor understanding of the basic precepts of palliative care. This is consistent with the current literature.

CONCLUSION

Advanced practice nurses should be educated on the principles of palliative care, as they are perfectly situated to advance the integration of early palliative care in the oncology setting.

Roles and Responsibilities of Nurses in Advance Care Planning in Palliative Care in the Acute Care Setting: A Scoping Review

Palliative care focuses on symptom management, discussion of treatment and care decisions, network organization, and support of the family. As part of the advance care planning (ACP) process, staff nurses in the acute care setting are often involved in all of the above areas. It is yet unclear what nurses' roles and responsibilities are and what skills are needed in the ACP process. The themes that staff nurses and advanced practice registered nurses (APRNs) discuss in relationship to ACP are manifold. This scoping review demonstrates that staff nurses' core role is advocating for the wishes and values of patients with any life-limiting disease. Staff nurses also serve as facilitators, educators, and advocates to help start ACP conversations and ease patients' transitions between settings based on well-discussed decisions. To be able to engage in ACP discussions, APRNs must have excellent communication skills. Continuous training to improve these skills is mandatory. In the future, clarifying the contribution of staff nurses and APRNs in the ACP process in relation to other members of the interprofessional team can lay the groundwork for improved interprofessional collaboration.

Health Care Providers' Views on the Transition Between Hospital and Primary Care in Patients in the Palliative Phase: A Qualitative Description Study

CONTEXT

Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals.

OBJECTIVES

To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care.

METHODS

This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically.

RESULTS

The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process.

CONCLUSION

Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

Healthcare providers' views and experiences of non-specialist palliative care in hospitals: A qualitative systematic review and thematic synthesis

BACKGROUND

Healthcare providers working in hospitals are frequently exposed to patients with palliative care needs. For most patients, these reflect non-specialist rather than specialist palliative care needs. Embedding palliative care principles early in patients' disease trajectories within acute care delivery in hospitals, however, is a challenge. How to best understand the experiences of those providing non-specialist palliative care in hospitals has not been systematically assessed.

AIM

To synthesise the evidence on healthcare providers' views and experiences of non-specialist palliative care in hospitals.

DESIGN

A qualitative systematic review and thematic synthesis using Thomas and Harden's thematic synthesis framework.

DATA SOURCES

Databases of MEDLINE, CINAHL, PsycINFO and EMBASE were searched from date of inception to March 2018. Studies were eligible for inclusion if they reported on healthcare providers' views and experiences of non-specialist palliative care in hospitals. Studies were appraised for quality but not excluded on that basis. The review was prospectively registered with the International Prospective Register of Systematic Reviews.

RESULTS

Thirty-nine papers of 37 studies were included, representing 985 hospital healthcare providers' views and experiences. Four major analytical themes emerged; 'Understanding of Palliative Care', 'Complexities of Communication', 'Hospital Ecosystem' and 'Doctors and Nurses - a Different Lens'.

CONCLUSIONS

Non-specialist palliative care in hospitals is operationalised as care in the last weeks and days of life. The organisation of acute care, inter-disciplinary working practices, clinician attitudes, poor communication structures and lack of education and training in palliative care principles exacerbates poor implementation of this care earlier for patients in hospitals.

Team approaches in palliative care: a review of the literature

Background:

Interdisciplinary team involvement is commonplace in many palliative care settings across the world. Teamwork is perceived by many experts as an indispensable functionality of palliative care teams. Significantly different structural and functional attributes of these teams between regional and organisational contexts could potentially act both as strengths and weaknesses towards their overall productivity. The sustainability and resilience of the team also has an indirect bearing on the team functioning.

Aim:

This article describes international evidence on dynamic palliative care teams with a view of how and when they function efficiently or adversely. Emphasis is also placed on studies that suggest means to mitigate the conflicts and limitations of teamwork in palliative care and related healthcare settings.

Findings:

Evidence strongly suggests that palliative care is best delivered through a multidisciplinary team approach.

Conclusion:

The overall performance of a healthcare team is largely determined by the supportive work environment built through effective communication, leadership skills and mutual respect.

Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study

PURPOSE

Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients' places of care and death.

METHOD

Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach.

RESULTS

Five inter-related factors were identified as contributing to the likelihood of patients' receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home.

CONCLUSIONS

Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.

Nurses' Interest in Independently Initiating End-of-Life Conversations and Palliative Care Consultations in a Suburban, Community Hospital

BACKGROUND

Patients who receive early palliative care consults have clinical courses and outcomes more consistent with their goals. Nurses have been shown to be advocates for early palliative care involvement and are able to lead advanced care planning discussions.

OBJECTIVE

The purpose of this study was to assess whether after a brief educational session, nurses at a suburban, community hospital could demonstrate knowledge of palliative care principles, would want to independently initiate end-of-life conversations with patients and families, and would want to place specialty palliative care consults.

DESIGN

Four 1 hour presentations were made at 4 nursing leadership council meetings from November through December 2015. Anonymous pre- and post-presentation surveys were distributed and collected in person. Setting/Participant: Nonprofit, suburban, community hospital in Maryland. Participants were full-time or part-time hospital employees participating in a nursing leadership council who attended the presentation.

MEASUREMENTS

We compared responses from pre- and post-presentation surveys.

RESULTS

Fifty nurses (19 departments) completed pre-presentation surveys (100% response rate) and 49 nurses completed post-presentation surveys (98% response rate). The average score on 7 index questions increased from 71% to 90%. After the presentations, 86% strongly agreed or agreed that nurses should be able to independently order a palliative care consult and 88% strongly agreed or agreed with feeling comfortable initiating an end-of-life conversation.

CONCLUSION

Brief educational sessions can teach palliative care principles to nurses. Most participants of the study would want to be able to directly consult palliative care and would feel comfortable initiating end-of-life conversations after this educational session.

Bereaved family members' perspectives on suffering among older rural cancer patients in palliative home nursing care: A qualitative study

Little is known about experiences with receiving home nursing care when old, living in a rural area, and suffering from end-stage cancer. The aim of this study was thus to investigate bereaved family members' perceptions of suffering by their older relatives when receiving palliative home nursing care. Qualitative semi-structured interviews were conducted with 10 family members, in Norway during autumn 2015, and directed content analysis guided by Katie Eriksson's theoretical framework on human suffering was performed upon the data. The two main categories identified reflected expressions of both suffering and well-being. Expressions of suffering were related to illness, to care and to life and supported the theory. Expressions of well-being were related to other people (e.g. familiar people and nurses), to home and to activity. The results indicate a need to review and possibly expand the perspective of what should motivate care. Nursing and palliative care that become purely disease and symptom-focused may end up with giving up and divert the attention to social and cultural factors that may contribute to well-being when cure is not the goal.

Palliative care team visits. Qualitative study through participant observation

OBJECTIVES

To describe the clinical encounters that occur when a palliative care team provides patient care and the features that influence these encounters and indicate whether they are favorable or unfavorable depending on the expectations and feelings of the various participants.

METHODS

A qualitative case study conducted via participant observation. A total of 12 observations of the meetings of palliative care teams with patients and families in different settings (home, hospital and consultation room) were performed. The visits were follow-up or first visits, either scheduled or on demand. Content analysis of the observation was performed.

RESULTS

The analysis showed the normal follow-up activity of the palliative care unit that was focused on controlling symptoms, sharing information and providing advice on therapeutic regimens and care. The environment appeared to condition the patients' expressions and the type of patient relationship. Favorable clinical encounter conditions included kindness and gratitude. Unfavorable conditions were deterioration caused by approaching death, unrealistic family objectives and limited resources.

CONCLUSION

Home visits from basic palliative care teams play an important role in patient and family well-being. The visits seem to focus on controlling symptoms and are conditioned by available resources.

Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study

INTRODUCTION

Provision of end-of-life (EOL) care in the emergency department has improved globally in recent years and has a different scope of interventions than traditional emergency medicine. In 2010, a regional hospital established the first ED EOL service in Hong Kong.

METHODS

The aim of this study was to understand emergency nurses' perceptions regarding the provision of EOL care in the emergency department. A qualitative approach was used with purposive sampling of 16 nurses who had experience in providing EOL care. Semi-structured, face-to-face interviews were conducted from May to October, 2014. All the interviews were transcribed verbatim for content analysis.

RESULTS

Four themes were identified: (1) doing good for the dying patients, (2) facilitating family engagement and involvement, (3) enhancing personal growth and professionalism, and (4) expressing ambiguity toward resource deployment.

DISCUSSION

Provision of EOL care in the emergency department can enhance patients' last moment of life, facilitate the grief and bereavement process of families, and enhance the professional development of staff in emergency department. It is substantiated that EOL service in the emergency department enriches EOL care in the health care system. Findings from this study integrated the perspectives on ED EOL services from emergency nurses. The integration of EOL service in other emergency departments locally and worldwide is encouraged.

Impact of provider level, training and gender on the utilization of palliative care and hospice in neuro-oncology: a North-American survey

Specialized palliative care (PC) services have emerged to address symptoms and provide end-of-life management for patients with brain tumors. The utilization patterns of PC in neuro-oncology are unknown. A 22-question survey was distributed to participants of the society for neuro-oncology annual meeting 2012 (n = 4487). Nonparametric methods including Wilcoxon two-sample and Kruskal-Wallis tests were used to assess differences in responses. 239 (5.3 %) evaluable responses were received; 79 % of respondents were physicians, and 17 % were nurses or midlevel providers. Forty-seven percent were medical or neuro-oncologists, 31 % neurosurgeons and 11 % radiation oncologists. Forty percent had no formal training in PC, 57 % had some formal training and 3 % completed a PC fellowship. Seventy-nine percent practiced in an academic setting. Of the respondents, 57 % referred patients to PC when symptoms required treatment and 18 % at end of life. Only 51 % of all providers felt comfortable dealing with end-of-life issues and symptoms, while 33 % did not. Fifty-one percent preferred a service named "Supportive Care" rather than "Palliative Care" (MDs > midlevel providers, p < 0.001), and 32 % felt that patient expectations for ongoing therapy hindered their ability to make PC referrals. Female gender, formal training in neuro-oncology and PC, and medical versus surgical neuro-oncology training were significantly associated with hospice referral, comfort in dealing with end-of-life issues, and ease of access to PC services. Provider level, specialty, gender, training in PC and neuro-oncology have significant impact on the utilization of PC and hospice in neuro-oncology.

Competências do enfermeiro para o cuidado paliativo na atenção domiciliar

Resumo Objetivo: Identificar competências do enfermeiro para o cuidado paliativo na atenção domiciliar. Métodos: Estudo exploratório que utilizou o método Delphi para identificar o consenso de enfermeiros que atuam na atenção domiciliar para com 43 competências elencadas em um questionário, com inclusão de escala de Likert de cinco pontos. Resultados: Na amostra de 20 enfermeiros, houve consenso para 18 competências gerais e 25 específicas com percentuais acima de 75% de concordância, e coeficiente alfa de Cronbach de 0,7 para todas as competências elencadas. O consenso favorável às competências propostas indica o reconhecimento do cuidado paliativo como prática assistencial de enfermagem na atenção domiciliar. Conclusão: O elenco de competências apresentou confiabilidade interna e fornece afirmações assertivas sobre a atuação do enfermeiro em cuidado paliativo na atenção domiciliar.