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Soo Rui Ting M, Nashi NB, Ang Lin Elaine K, Hooi BMY. Effect of a multidisciplinary ward-based intervention on end-of-life care for general medicine patients. Palliat Support Care 2022; 20:813-817. [PMID: 34663485 DOI: 10.1017/s1478951521001723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Providing good end-of-life (EOL) care for noncancer patients has been made a national priority in Singapore. A combined medical and nursing ward-based intervention known as the EOL care plan was piloted in a general medicine ward at our institution, aiming to guide key aspects of EOL care. The aim of this study is to assess the EOL care plan's effect on EOL care for general medicine patients. METHOD We conducted a retrospective cohort study on inpatients who died in a general ward under the discipline "General Medicine" from May to October 2019. We collected data around symptom management, rationalization of care and communication with families. The primary analysis compared care received by patients who died in the pilot ward with that of a control group of patients who died in other wards. RESULTS In total, 112 records were included in the analysis. Pain assessment was more common in the pilot ward compared with the control group (35.3% vs. 6.3%, p < 0.001), as were anti-psychotic prescriptions for delirium (64.7% vs. 24.4%, p = 0.001). Fewer patients received blood glucose monitoring in the last 48 h of life in the pilot ward (69.5% vs. 35.3%, p = 0.007). There were also less frequent parameters monitoring in the pilot ward (p < 0.004). SIGNIFICANCE OF RESULTS The implementation of the EOL care plan was associated with process-level indicators of better EOL care, suggesting that it could have a significant positive impact when implemented on a wider scale.
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Affiliation(s)
- Michelle Soo Rui Ting
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Norshima Binte Nashi
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Kai Ang Lin Elaine
- Division of Oncology Nursing, National Cancer Institute Singapore, National University Hospital, Singapore, Singapore
| | - Benjamin M Y Hooi
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
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Croker A, Fisher K, Hungerford P, Gourlay J, May J, Lees S, Chapman J. Developing a meta-understanding of 'human aspects' of providing palliative care. Palliat Care Soc Pract 2022; 16:26323524221083679. [PMID: 35281714 PMCID: PMC8915236 DOI: 10.1177/26323524221083679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/01/2022] [Indexed: 01/03/2023] Open
Abstract
Objectives: Our intention was to develop a meta-understanding of the ‘human aspects’ of providing palliative care. Integral to developing this meta-understanding was recognising the individuality of people, their varied involvements, situations, understandings, and responses, and the difficulty in stepping back to get a whole view of this while being in the midst of providing palliative care. We intended for this meta-understanding to inform reflections and sense-making conversations related to people’s changing situations and diverse needs. Methods: Using collaborative inquiry, this qualitative research was undertaken ‘with’ clinicians rather than ‘on’ them. Our team (n = 7) was composed of palliative care clinicians and researchers from a co-located rural health service and university. We explored our personal perceptions and experiences through a series of 12 meetings over 8 months. In addition, through five focus groups, we acccessed perceptions and experiences of 13 purposively sampled participants with a range of roles as carers and/or healthcare providers. Data were dialogically and iteratively interpreted. Findings: Our meta-understanding of ‘human aspects’ of providing palliative care, represented diagrammatically in a model, is composed of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING. ATTRIBUTES OF HUMANITY are death’s inevitability, suffering’s variability, compassion’s dynamic nature, and hope’s precariousness. ACTIONS OF CARING include recognising and responding, aligning expectations, valuing relationships, and using resources wisely. The meta-understanding is a framework to keep multiple complex concepts ‘in view’ as they interrelate with each other. Significance of findings: Our meta-understanding, highlighting ‘human aspects’ of providing palliative care, has scope to embrace complexity, uncertainty, and the interrelatedness of people in the midst of resourcing, requiring, and engaging in palliative care. Questions are posed for this purpose. The non-linear diagrammatic representation of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING facilitates multiple ways of engaging and revisiting palliative care situations or navigating changes within and across them.
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Affiliation(s)
- Anne Croker
- Department of Rural Health (UONDRH), The University of Newcastle, 114 - 148 Johnston Street, Tamworth, NSW 2340, Australia
| | - Karin Fisher
- Department of Rural Health (UONDRH), The University of Newcastle, Tamworth, NSW, Australia
| | | | - Jonathan Gourlay
- Hunter New England Local Health District, Tamworth, NSW, Australia
| | - Jennifer May
- Department of Rural Health (UONDRH), The University of Newcastle, Tamworth, NSW, Australia
| | - Shannon Lees
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review. Int Emerg Nurs 2022; 61:101153. [PMID: 35240435 DOI: 10.1016/j.ienj.2022.101153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION End of life (EOL) care in the Emergency Department (ED) requires focused, person-centred care to meet the needs of this vulnerable cohort of patients. METHODS An integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted. Studies were included if they were primary research relating to patients in the ED at the EOL, and/or evaluated EOL care pathways in the ED. Databases OVID Emcare, OVID Medline, and Scopus were searched from 1966-September 2021; followed by screening and appraisal. Articles were compared and data grouped into categories. RESULTS Eleven research articles were included generating three categories for EOL care in ED. 1) tools/criteria to identify patients who may require EOL care in ED; 2) processes for providing EOL care, and 3) implementation methods/frameworks to support the uptake of EOL care processes. CONCLUSION There were some commonalities in the criteria used to identify patients who may be at their EOL and the interventions implemented thereafter. There was no standardised process for screening for or treating EOL care needs in the ED. Further research is required to determine the impact that EOL care pathways have on patient and health service outcomes to inform strategies for future policy development.
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Bayuo J, Anago EK, Agyei FB, Salifu Y, Kyei Baffour P, Atta Poku C. "Resuscitate and Push": End-of-Life Care Experiences of Healthcare Staff in the Emergency Department - A Hermeneutic Phenomenological Study. J Palliat Care 2021; 37:494-502. [PMID: 34713731 DOI: 10.1177/08258597211050740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Care in the emergency department focuses significantly on delivering lifesaving/ life-sustaining clinical actions, often with limited attention to health-related suffering even at the end-of-life. How healthcare staff experience and navigate through the end-of-life phase remains minimally explored. Thus, this study aimed to uncover the lived experiences of emergency department staff at the end-of-life. METHODS van Manen's hermeneutic phenomenological approach was used. Nineteen healthcare staff were purposively recruited and interviewed. Interviews were audio-taped, transcribed verbatim, and thematic categories formulated. The existential lifeworld themes (corporeality, relationality, spatiality, and temporality) were used as heuristic guides for reflecting and organizing the lived experiences of participants. RESULTS The overarching category, 'resuscitate and push', was captured as corporeality (resisting death and dying); relationality (connectedness to the body of the patient; and lacking support for family and self); spatiality (navigating through a liminal space and lack of privacy for patients); and temporality (having limited to no time for end-of-life care and grieving). The end-of-life space was unpleasant. Although participants experienced helplessness and feelings of failure, support systems to help them to navigate through these emotions were lacking. Grief was experienced covertly and concealed by the entry of a new patient. CONCLUSION End-of-life in the emergency department is poorly defined. In addition to shifting from the traditional emergency care model to support the streamlining of palliative care in the department, staff will require support with navigating through the liminal space, managing their grief, and developing a better working relationship with patients/ families.
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Affiliation(s)
- Jonathan Bayuo
- The Hong Kong Polytechnic University, Hung Hom, Hong Kong
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Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
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Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
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Williams M, Cardona-Morrell M, Stevens P, Bey J, Smith Glasgow M. Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital. Int J Nurs Stud 2017; 75:147-153. [DOI: 10.1016/j.ijnurstu.2017.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 01/13/2023]
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Tse JWK, Hung MSY, Pang SMC. Emergency Nurses' Perceptions of Providing End-of-Life Care in a Hong Kong Emergency Department: A Qualitative Study. J Emerg Nurs 2016; 42:224-32. [PMID: 27033338 DOI: 10.1016/j.jen.2015.10.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 09/11/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
| | - Maria Shuk Yu Hung
- Hong Kong Special Administrative Region of the People's Republic of China
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Sleeman KE, Koffman J, Bristowe K, Rumble C, Burman R, Leonard S, Noble J, Dampier O, Bernal W, Morgan M, Hopkins P, Prentice W, Higginson IJ. 'It doesn't do the care for you': a qualitative study of health care professionals' perceptions of the benefits and harms of integrated care pathways for end of life care. BMJ Open 2015; 5:e008242. [PMID: 26369795 PMCID: PMC4577969 DOI: 10.1136/bmjopen-2015-008242] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To understand healthcare professionals' perceptions of the benefits and potential harms of integrated care pathways for end-of-life care, to inform the development of future interventions that aim to improve care of the dying. DESIGN Qualitative interview study with maximum variation sampling and thematic analysis. PARTICIPANTS 25 healthcare professionals, including doctors, nurses and allied health professionals, interviewed in 2009. SETTING A 950-bed South London teaching hospital. RESULTS 4 main themes emerged, each including 2 subthemes. Participants were divided between (1) those who described mainly the benefits of integrated care pathways, and (2) those who talked about potential harms. Benefits focused on processes of care, for example, clearer, consistent and comprehensive actions. The recipients of these benefits were staff members themselves, particularly juniors. For others, this perceived clarity was interpreted as of potential harm to patients, where over-reliance on paperwork lead to prescriptive, less thoughtful care, and an absolution from decision-making. Independent of their effects on patient care, integrated care pathways for dying had (3) a symbolic value: they legitimised death as a potential outcome and were used as a signal that the focus of care had changed. However, (4) a weak infrastructure, including scanty education and training in end-of-life care and a poor evidence base, that appeared to undermine the foundations on which the Liverpool Care Pathway was built. CONCLUSIONS The potential harms of integrated care pathways for the dying identified in this study were reminiscent of criticisms subsequently published by the Neuberger review. These data highlight: (1) the importance of collecting, reporting and using qualitative data when developing and evaluating complex interventions; (2) that comprehensive education and training in palliative care is critical for the success of any new intervention; (3) the need for future interventions to be grounded in patient-centred outcomes, not just processes of care.
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Affiliation(s)
- Katherine E Sleeman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Jonathan Koffman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Katherine Bristowe
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Caroline Rumble
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Rachel Burman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Sara Leonard
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Jo Noble
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Odette Dampier
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - William Bernal
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Myfanwy Morgan
- Division of Health and Social Care Research, King's College London, London, UK
| | - Philip Hopkins
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Wendy Prentice
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Irene J Higginson
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, van der Heide A, Deliens L. Development of the care programme for the last days of life for older patients in acute geriatric hospital wards: a phase 0-1 study according to the Medical Research Council Framework. BMC Palliat Care 2015; 14:24. [PMID: 25956386 PMCID: PMC4464229 DOI: 10.1186/s12904-015-0025-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effects of the Liverpool Care Pathway (LCP) have never been investigated in older patients dying in acute geriatric hospital wards and its content and implementation have never been adapted to this specific setting. Moreover, the LCP has recently been phased out in the UK hospitals. For that reason, this study aims to develop a new care programme to improve care in the last days of life for older patients dying in acute geriatric wards. METHODS We conducted a phase 0-1 study according to the Medical Research Council Framework. Phase 0 consisted of a review of existing LCP programmes from the UK, Italy, and the Netherlands, a literature review to identify key factors for a successful LCP implementation and an analysis of the concerns raised in the UK. In phase 1, we developed a care programme for the last days of life for older patients dying in acute geriatric wards based on the results of phase 0. The care programme was reviewed and refined by two nurses and two physicians working in an acute geriatric ward and by two experts from Italy and the Netherlands. RESULTS Phase 0 resulted in the identification of nine important components within the LCP programmes, five key factors for a successful LCP implementation and a summary of the LCP concerns raised in the UK. Based on these findings we developed a new care programme consisting of (1) an adapted LCP document or Care Guide for the older patients dying in an acute geriatric ward, (2) supportive documentation, and (3) an implementation guide to assist health care staff in implementing the care programme on the acute geriatric ward. CONCLUSIONS Based on the existing LCP programmes and taking into account the key factors for successful LCP implementation as well as the concerns raised in the UK, we developed a care programme for the last days of life and modelled it to the acute geriatric hospital wards after gaining feedback from health professionals caring for older hospitalized patients.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
| | | | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium.
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Cardona-Morrell M, Hillman K. Development of a tool for defining and identifying the dying patient in hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL). BMJ Support Palliat Care 2015; 5:78-90. [PMID: 25613983 PMCID: PMC4345773 DOI: 10.1136/bmjspcare-2014-000770] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/23/2014] [Accepted: 11/23/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To develop a screening tool to identify elderly patients at the end of life and quantify the risk of death in hospital or soon after discharge for to minimise prognostic uncertainty and avoid potentially harmful and futile treatments. DESIGN Narrative literature review of definitions, tools and measurements that could be combined into a screening tool based on routinely available or obtainable data at the point of care to identify elderly patients who are unavoidably dying at the time of admission or at risk of dying during hospitalisation. MAIN MEASUREMENTS Variables and thresholds proposed for the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL screening tool) were adopted from existing scales and published research findings showing association with either in-hospital, 30-day or 3-month mortality. RESULTS Eighteen predictor instruments and their variants were examined. The final items for the new CriSTAL screening tool included: age ≥65; meeting ≥2 deterioration criteria; an index of frailty with ≥2 criteria; early warning score >4; presence of ≥1 selected comorbidities; nursing home placement; evidence of cognitive impairment; prior emergency hospitalisation or intensive care unit readmission in the past year; abnormal ECG; and proteinuria. CONCLUSIONS An unambiguous checklist may assist clinicians in reducing uncertainty patients who are likely to die within the next 3 months and help initiate transparent conversations with families and patients about end-of-life care. Retrospective chart review and prospective validation will be undertaken to optimise the number of prognostic items for easy administration and enhanced generalisability. Development of an evidence-based tool for defining and identifying the dying patient in hospital: CriSTAL.
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Affiliation(s)
- Magnolia Cardona-Morrell
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Kensington, NSW 2052, Australia
| | - Ken Hillman
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales & Liverpool Hospital, Liverpool BC 1871, New South Wales, Australia
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Richardson P, Greenslade J, Shanmugathasan S, Doucet K, Widdicombe N, Chu K, Brown A. PREDICT: a diagnostic accuracy study of a tool for predicting mortality within one year: who should have an advance healthcare directive? Palliat Med 2015; 29:31-7. [PMID: 25062815 DOI: 10.1177/0269216314540734] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND CARING is a screening tool developed to identify patients who have a high likelihood of death in 1 year. AIM This study sought to validate a modified CARING tool (termed PREDICT) using a population of patients presenting to the Emergency Department. SETTING/PARTICIPANTS In total, 1000 patients aged over 55 years who were admitted to hospital via the Emergency Department between January and June 2009 were eligible for inclusion in this study. DESIGN Data on the six prognostic indicators comprising PREDICT were obtained retrospectively from patient records. One-year mortality data were obtained from the State Death Registry. Weights were applied to each PREDICT criterion, and its final score ranged from 0 to 44. Receiver operator characteristic analyses and diagnostic accuracy statistics were used to assess the accuracy of PREDICT in identifying 1-year mortality. RESULTS The sample comprised 976 patients with a median (interquartile range) age of 71 years (62-81 years) and a 1-year mortality of 23.4%. In total, 50% had ≥1 PREDICT criteria with a 1-year mortality of 40.4%. Receiver operator characteristic analysis gave an area under the curve of 0.86 (95% confidence interval: 0.83-0.89). Using a cut-off of 13 points, PREDICT had a 95.3% (95% confidence interval: 93.6-96.6) specificity and 53.9% (95% confidence interval: 47.5-60.3) sensitivity for predicting 1-year mortality. PREDICT was simpler than the CARING criteria and identified 158 patients per 1000 admitted who could benefit from advance care planning. CONCLUSION PREDICT was successfully applied to the Australian healthcare system with findings similar to the original CARING study conducted in the United States. This tool could improve end-of-life care by identifying who should have advance care planning or an advance healthcare directive.
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Affiliation(s)
- Philip Richardson
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia School of Medicine, The University of Queensland, Brisbane, QLD, Australia School of Public Health, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Katherine Doucet
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Neil Widdicombe
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia Intensive Care Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Kevin Chu
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Anthony Brown
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia School of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia
| | - Amy P Abernethy
- Division of Medical Oncology, Department of Medicine, Duke Center for Learning Health Care, Duke Clinical Research Institute, Durham, NC 27710, USA.
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Reid C, Gibbins J, Bloor S, Burcombe M, McCoubrie R, Forbes K. Healthcare professionals' perspectives on delivering end-of-life care within acute hospital trusts: a qualitative study. BMJ Support Palliat Care 2013; 5:490-5. [PMID: 24644187 DOI: 10.1136/bmjspcare-2013-000468] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 09/09/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The quality of end-of-life (EOL) care in acute hospitals is variable and interventions to improve this care, such as EOL care pathways, are not always used. The underlying reasons for this variability are not fully understood. We explored healthcare professionals' views on delivering EOL care within an acute hospital trust in the South West of England. METHODS We employed qualitative methods (focus groups, in-depth interviews and questerviews) within a study investigating the impact of a simple EOL tool on the care of dying patients. We invited a range of staff of all grades with experience in caring for dying patients from medicine, surgery and care of the elderly teams to participate. RESULTS Six focus groups, seven interviews and five questerviews were conducted. Two main themes emerged: (a) delays (difficulties and avoidance) in diagnosing dying and (b) the EOL tool supporting staff in caring for the dying. Staff acknowledged that the diagnosis of dying was often made late; this was partly due to prognostic uncertainty but compounded by a culture that did not acknowledge death as a possible outcome until death was imminent. Both the medical and nursing staff found the EOL tool useful as a means of communicating ceilings of care, ensuring appropriate prescribing for EOL symptoms, and giving nurses permission to approach the bedside of a dying patient. CONCLUSIONS The culture of avoiding death and dying in acute hospitals remains a significant barrier to providing EOL care, even when EOL tools are available and accepted by staff.
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Affiliation(s)
- Colette Reid
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Jane Gibbins
- Cornwall Hospice Care, St Julia's Hospice, Hayle, Cornwall, UK
| | - Sophia Bloor
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Melanie Burcombe
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Rachel McCoubrie
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Karen Forbes
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
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Bloomer MJ, Endacott R, O'Connor M, Cross W. The 'dis-ease' of dying: challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study. Palliat Med 2013; 27:757-64. [PMID: 23442881 DOI: 10.1177/0269216313477176] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Changes in health care and an ageing population have meant that more people are dying in the acute hospital setting. While palliative care principles have resulted in quality care for the dying, many patients die in an acute care, still receiving aggressive/resuscitative care. AIMS The aims were to explore nurses' 'recognition of' and 'responsiveness to' dying patients and to understand the nurses' influence on end-of-life care. DESIGN A qualitative approach was taken utilising non-participant observation to elicit rich data, followed by focus groups and individual semi-structured interviews for clarification. SETTING/PARTICIPANTS This study was conducted in two acute medical wards in one health service, identified as having the highest rates of death, once palliative care and critical care areas were excluded. Twenty-five nurses consented to participate, and 20 episodes of observation were conducted. RESULTS Nurses took a passive role in recognising dying, providing active care until a medical officer's declaration of dying. Ward design, nurse allocation and nurses' attitude to death impacts patient care. End-of-life care in a single room can have negative consequences for the dying. Nurses demonstrated varying degrees of discomfort, indicating that they were underprepared for this role. CONCLUSION When patients are terminally ill, acknowledgement of dying is essential in providing appropriate care. It should not be assumed that all nurses are adequately prepared to provide dying care. Further work is necessary to investigate how the attitudes of nurses towards caring for dying patients in the acute hospital setting may impact care of the dying patient.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Monash University, Melbourne, VIC, Australia
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McConnell T, O'Halloran P, Porter S, Donnelly M. Systematic realist review of key factors affecting the successful implementation and sustainability of the Liverpool care pathway for the dying patient. Worldviews Evid Based Nurs 2013; 10:218-37. [PMID: 23489967 DOI: 10.1111/wvn.12003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Liverpool Care Pathway (LCP) is recommended internationally as a best practice model for the care of patients and their families at the end of life. However, a recent national audit in the United Kingdom highlighted shortcomings; and understanding is lacking regarding the processes and contextual factors that affect implementation. AIM To identify and investigate factors that help or hinder successful implementation and sustainability of the LCP. METHODS Electronic databases (Medline, CINAHL, British Nursing Index, Science Direct) and grey literature were searched, supplemented by citation tracking, in order to identify English language papers containing information relevant to the implementation of the LCP. Using a realist review approach, we systematically reviewed all relevant studies that focused on end of life care and integrated care pathway processes and identified theories that explained how the LCP and related programmes worked. RESULTS Fifty-eight papers were included in the review. Key factors identified were: a dedicated facilitator, education and training, audit and feedback, organisational culture, and adequate resources. DISCUSSION We discuss how these factors change behaviour by influencing the beliefs, attitudes, motivation and confidence of staff in relation to end of life care, and how contextual factors moderate behaviour change. CONCLUSIONS The implementation process recommended by the developers of the LCP is necessary but not sufficient to ensure successful implementation and sustainability of the pathway. The key components of the intervention (a dedicated facilitator, education and training, audit and feedback) must be configured to influence the beliefs of staff in relation to end of life care, and increase their motivation and self-efficacy in relation to using the LCP. The support of senior managers is vital to the release of necessary resources, and a dominant culture of cure, which sees every death as a failure, works against effective communication and collaboration in relation to the LCP.
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Affiliation(s)
- Tracey McConnell
- Doctoral student, School of Nursing and Midwifery, Queen's University of Belfast, Belfast, Northern Ireland
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Forero R, McDonnell G, Gallego B, McCarthy S, Mohsin M, Shanley C, Formby F, Hillman K. A Literature Review on Care at the End-of-Life in the Emergency Department. Emerg Med Int 2012; 2012:486516. [PMID: 22500239 PMCID: PMC3303563 DOI: 10.1155/2012/486516] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 11/21/2011] [Accepted: 12/13/2011] [Indexed: 12/18/2022] Open
Abstract
The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.
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Affiliation(s)
- Roberto Forero
- Simpson Centre for Health Services Research, South Western Sydney Clinical School (Liverpool Hospital) and The Australian Institute of Health Innovation (AIHI), University of New South Wales, Level 1, AGSM Building (G27), Kensington Campus, Gate 11, Botany Street, Randwick, NSW 2052, Australia
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Martinsson L, Fürst CJ, Lundström S, Nathanaelsson L, Axelsson B. Registration in a quality register: a method to improve end-of-life care--a cross-sectional study. BMJ Open 2012; 2:bmjopen-2012-001328. [PMID: 22936818 PMCID: PMC3432841 DOI: 10.1136/bmjopen-2012-001328] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Structured methods to assess and support improvement in the quality of end-of-life care are lacking and need to be developed. This need is particularly high outside the specialised palliative care. This study examines whether participation in a national quality register increased the quality of end-of-life care. DESIGN This study is a cross-sectional longitudinal register study. SETTING The Swedish Register of Palliative Care (SRPC) collects data about end-of-life care for deaths in all types of healthcare units all over Sweden. Data from all 503 healthcare units that had reported patients continuously to the register during a 3-year period were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES Data on provided care during the last weeks of life were compared year-by-year with logistic regression. PARTICIPANTS The study included a total 30 283 patients. The gender distribution was 54% women and 46% men. A total of 60% of patients in the study had a cancer diagnosis. RESULTS Provided end-of-life care improved in a number of ways. The prevalence of six examined symptoms decreased. The prescription of 'as needed' medications for pain, nausea, anxiety and death rattle increased. A higher proportion of patients died in their place of preference. The patient's next of kin was more often offered a follow-up appointment after the patient's death. No changes were seen with respect to providing information to the patient or next of kin. CONCLUSIONS Participation in a national quality register covariates with quality improvements in end-of-life care over time.
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Affiliation(s)
- Lisa Martinsson
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Carl Johan Fürst
- Stockholm Sjukhem Foundation and Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Staffan Lundström
- Stockholm Sjukhem Foundation and Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
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Abstract
AIMS To discuss the intricacies of the decision-making process about initiating end-of-life care pathways. BACKGROUND Internationally, enhancing the quality of end-of-life care has become a central concern in governments' health policies. Despite limited empirical evaluation, end-of- life care pathways have been championed and widely adopted as complex interventions to enhance end-of-life care worldwide. DATA SOURCES A literature search of established electronic databases was conducted for published articles in English addressing decision-making and end-of-life care pathways between 1997-2010. Manual searches of relevant journals and internet sites were also undertaken. DISCUSSION The initiation of an end-of-life care pathway marks the transition to the terminal phase of care. Although guidance for commencing these pathways exists, this may not overcome the complexities of the decision-making process, which must be viewed in context, namely: marking the transition to terminal care, dealing with ambiguity, reaching professional consensus and engaging patients and families. Implications for nursing. Nurses in all care settings have an important role in easing the transition to end-of- life care. Accordingly, nurses need not only an appreciation of end-of-life care pathways, but the complexities surrounding the decision to commence a pathway and their role within. CONCLUSION The initiation of an end-of-life care pathway is contingent on the outcome of a complex decision-making process which is rarely explored and poorly understood.
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Affiliation(s)
- Tessa Watts
- Department of Nursing, College of Human and Health Sciences, Swansea University, Swansea, UK.
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Bloomer MJ, Moss C, Cross WM. End-of-life care in acute hospitals: an integrative literature review. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1752-9824.2011.01094.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Phillips JL, Halcomb EJ, Davidson PM. End-of-life care pathways in acute and hospice care: an integrative review. J Pain Symptom Manage 2011; 41:940-55. [PMID: 21398083 DOI: 10.1016/j.jpainsymman.2010.07.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 07/24/2010] [Accepted: 07/29/2010] [Indexed: 11/26/2022]
Abstract
CONTEXT Over the past decade, there has been widespread adoption of end-of-life care pathways as a tool to better manage care of the dying in a variety of care settings. The adoption of various end-of-life care pathways has occurred despite lack of robust evidence for their use. OBJECTIVES This integrative review identified published studies evaluating the impact of an end-of-life care pathway in the acute and hospice care setting from January 1996 to April 2010. METHODS A search of the electronic databases Scopus and Cumulative Index of Nursing and Allied Health Literature as well as Medline and the World Wide Web were undertaken. This search used Medical Subject Headings key words including "end-of-life care," "dying," "palliative care," "pathways," "acute care," and "evaluation." Articles were reviewed by two authors using a critical appraisal tool. RESULTS The search revealed 638 articles. Of these, 26 articles met the inclusion criteria for this integrative review. No randomized controlled trials were reported. The majority of these articles reported baseline and post implementation pathway chart audit data, whereas a smaller number were local, national, or international benchmarking studies. Most of the studies emerged from the United Kingdom, with a smaller number from the United States, The Netherlands, and Australia. CONCLUSION Existing data demonstrate the utility of the end-of-life pathway in improving care of the dying. The absence of randomized controlled trial data, however, precludes definitive recommendations and underscores the importance of ongoing research.
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Affiliation(s)
- Jane L Phillips
- The Cunningham Centre for Palliative Care and The University of Notre Dame, Darlinghurst, New South Wales, Australia.
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Hemington-Gorse SJ, Clover AJP, Macdonald C, Harriott J, Richardson P, Philp B, Shelley O, Dziewulski P. Comfort care in burns: the Burn Modified Liverpool Care Pathway (BM-LCP). Burns 2011; 37:981-5. [PMID: 21493007 DOI: 10.1016/j.burns.2011.03.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 03/10/2011] [Accepted: 03/21/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.
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Affiliation(s)
- S J Hemington-Gorse
- St Andrew's Centre for Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom.
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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