Feeling like a burden to others: a systematic review focusing on the end of life

Electronic symptom monitoring for home-based palliative care: A systematic review

BACKGROUND

Coordination and communication challenges in home-based palliative care complicate transitions from hospital care. Electronic symptom monitoring enables real-time data collection, enhancing patient-provider communication. However, a systematic evaluation of its effectiveness in home-based palliative care is lacking.

AIM

To analyze the feasibility, effectiveness, and limitations of electronic symptom monitoring in home-based palliative care, assess the evidence quality, identify the evidence gap, and suggest implications for future research and practice.

DESIGN

This study uses systematic review, meta-analysis, and narrative synthesis (CRD42023457977) to analyze relevant studies until September 2023.

DATA SOURCES

Electronic searches in MEDLINE, CENTRAL, and Embase until September 2023, complemented by hand-searching of references and citations.

RESULTS

This study included twenty studies. The majority of patients positively engage in electronic symptom monitoring, which could improve their quality of life, physical and emotional well-being, and symptom scores without a significant increase in costs. However, firm conclusions about the effects of electronic symptom monitoring on outcomes like survival, hospital admissions, length of stay, emergency visits, and adverse events were limited due to significant variability in the reported data or inadequate statistical power.

CONCLUSION

Introducing electronic symptom monitoring in home-based palliative care holds potential for enhancing patient-reported outcomes, potentially decreasing hospital visits and costs. However, inconsistency in current studies arising from diverse monitoring systems obstructs comparability. To advance, future high-quality research should employ standardized follow-up periods and established scales to better grasp the benefits of electronic symptom monitoring in home-based palliative care.

Exploring geriatric trauma unit experiences through patients' eyes: a qualitative study

INTRODUCTION

The surgical management of older patients is complex due to age-related underlying comorbidities and decreased physiological reserves. Comanaged care models, such as the Geriatric Trauma Unit, are proven effective in treating the complex needs of patients with fall-related injuries. While patient-centered care is an important feature of these comanaged care models, there has been minimal research dedicated to investigating the patient experience within Geriatric Trauma Units. Therefore, it remains uncertain whether the Geriatric Trauma Unit's emphasis on a patient-centered approach truly manifests in these interactions. This study explores how patients with fall-related injuries admitted to a Geriatric Trauma Unit perceive and experience patient-centered care during hospitalization.

METHODS

This qualitative generic study was conducted in three teaching hospitals that integrated the principles of comanaged care in trauma care for older patients. Between January 2021 and May 2022, 21 patients were interviewed.

RESULTS

The findings highlight the formidable challenges that older patients encounter during their treatment for fall-related injuries, which often signify a loss of independence and personal autonomy. The findings revealed a gap in the consistent and continuous implementation of patient-centered care, with many healthcare professionals still viewing patients mainly through the lens of their injuries, rather than as individuals with distinct healthcare needs. Although focusing on fracture-specific care and physical rehabilitation aligns with some patient preferences, overlooking broader needs undermines the comprehensive approach to care in the Geriatric Trauma Unit.

CONCLUSION

Effective patient-centered care in Geriatric Trauma Units requires full adherence to its core elements: patient engagement, strong patient-provider relationships, and a patient-focused environment. This study shows that deviations from these principles can undermine care, emphasizing the need for a holistic approach that extends beyond treating immediate medical conditions.

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force

BACKGROUND

Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.

AIM

To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.

METHODS

A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.

RESULTS

This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.

CONCLUSIONS

Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

A scoping literature review of factors influencing cancer patients' self-perceived burden

PURPOSE

A cancer diagnosis disrupts the peaceful lives and plans of patients and even their caregivers, and patients can easily feel burdened when they are being cared for by others. However, the influencing factors of self-perceived burden (SPB) have not been summarized, and related research is still in its infancy. This review explores factors related to the SPB of cancer patients and identifies future research directions.

METHOD

A systematic search, including trolling through six electronic databases, was conducted to identity articles published in English and Chinese from January 2003 to April 2022, using key terms related to cancer patients' burden on others; a manual search was also performed on the articles' reference lists.

RESULTS

Thirty-three articles were identified. The content was described into three groups: patient-related factors, caregiver-related factors, and family-related (financial) factors. Despite the heterogeneity, patients' physical/disease factors, psychological factors, social factors, caregiver type, quality of care provided, caregiver physical and psychological status, and financial factors were all correlated with SPB.

CONCLUSIONS

This literature review shows that SPB imposes a huge burden on cancer patients, and that SPB in cancer patients is influenced by patient-related factors, caregiver-related factors, and family factors. These influencing factors directly or indirectly affect SPB. In addition, SPB is complex and studies related to its factors deserve a further detailed analysis based on the actual situation of the patients in order to make the results more accurate and relevant.

Assessing Burdening Guilt and Its Correlates

Burdening guilt refers to the belief that one's emotions, needs, and ways of being are a burden to others, and is one type of interpersonal guilt proposed by the control-mastery theory (CMT). The aim of this article is to validate two new measures of burdening guilt. In the two studies conducted, we examined the psychometric properties of these scales and the relationship between burdening guilt and self-perceived burden (burdensomeness), self-esteem, shame, anxiety, depression, mental health, attachment insecurity, adverse childhood experiences, social desirability, empathy, and suicidal ideation. In Study 1, we presented a newly developed Burdening Guilt Rating Scale (BGRS) and its correlation with measures of the abovementioned dimensions. In Study 2 we verified, through confirmatory factor analysis and correlation techniques, the possibility of expanding the Interpersonal Guilt Rating Scale-15 with a shorter, 5-item burdening guilt scale derived from the BGRS, and showed that this shorter scale correlates similarly to the longer one. Findings allowed us to validate these new scales providing empirical measures of burdening guilt-a theoretical concept with important clinical implications.

Understanding regional variation in euthanasia using geomedical frameworks: a critical ethical reflection

Considerable geographical variation in the uptake of euthanasia has been reported: some municipalities in the Netherlands have a 25 times higher euthanasia rate than other municipalities. Current 'geomedical' frameworks for interpreting practice variation in health care utilization seem inadequately tailored to understand regional variation in morally controversial procedures such as euthanasia. The aim of this conceptual article is threefold: i) to add relevant medical ethical principles to current frameworks; ii) to provide a four-step ethical-geomedical model for the interpretation of geographical differences in the utilization of health care in general and for ethically controversial treatments in specific; iii) to gain better understanding of the existing geographical variation in the incidence of euthanasia by using this framework in our analysis.

On taking up space: a qualitative inquiry of depression in older adults with cancer

OBJECTIVE

To identify the phenomenology of depression in older adults with cancer (OACs) in order to improve the accuracy of depression screening for this population.

METHOD

Inclusion criteria were: ≥70 years old, history of cancer, no cognitive impairment or severe psychopathology. Participants completed a demographic questionnaire, a diagnostic interview, and a qualitative interview. Using a Thematic Content Analysis framework, critical themes, passages, and phrases used by patients to describe their perceptions of depression and how it is experienced were identified. Particular attention was paid to divergences between depressed and non-depressed participants.

RESULTS

Among 26 OACs (13 depressed, 13 non-depressed), qualitative analyses revealed four major themes indicative of depression (i.e. anhedonia, reduction in social relationships/loneliness, lack of meaning and purpose, lack of usefulness/feeling like a burden) and four minor themes (i.e. attitude towards treatment, mood, regret/guilt, physical symptoms/limitations). Themes of adaptation and acceptance of symptoms also emerged.

CONCLUSIONS

Of the eight themes identified, only two overlap with DSM criteria. This supports the need to develop assessment methods of depression in OACs that are less reliant on DSM criteria and distinct from existing measures. This may improve the ability to identify depression in this population.

Family involvement in euthanasia or Physician Assisted Suicide and dementia: A systematic review

OBJECTIVE

To assess how families are involved in situations of euthanasia or physician assisted suicide (PAS) in dementia.

DESIGN

Systematic review searching literature in nine databases from inception up to October 2021. We included studies on family involvement in euthanasia from the perspective of persons with dementia and family caregivers. Themes were formulated through thematic analysis. The design was registered at Prospero (CRD42022298215).

RESULTS

We assessed 215 of 4038 studies in full text; 19 met the inclusion criteria of which 13 empirical studies. Themes included for people with dementia: being a burden; stage of dementia, and permissibility of euthanasia/PAS. Themes for family were the burden of care, responsibility toward the euthanasia or PAS wish, permissibility of euthanasia/PAS.

CONCLUSION

The wish for euthanasia/PAS arises in situations of burdensome care and fear of future deterioration. The family feels entrusted with the responsibility to enact upon the death wish. In shaping this responsibility, four roles of family can be distinguished: carer, advocate, supporter, and performer. Family as in need of support themselves is understudied.

Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach

PURPOSE

Data are scarce regarding the experience of critically ill patients at high risk of death. Identifying their concerns could allow clinicians to better meet their needs and align their end-of-life trajectory with their preferences and values. We aimed to identify concerns expressed by conscious patients at high risk of dying in the intensive care unit (ICU).

METHODS

Multiple source multicentre study. Concerns expressed by patients were collected from five different sources (literature review, panel of 50 ICU experts, prospective study in 11 ICUs, in-depth interviews with 17 families and 15 patients). All qualitative data collected were analyzed using thematic content analysis.

RESULTS

The five sources produced 1307 concerns that were divided into 7 domains and 41 sub-domains. After removing redundant items and duplicates, and combining and reformulating similar items, 28 concerns were extracted from the analysis of the data. To increase accuracy, they were merged and consolidated, and resulted in a final list of 15 concerns pertaining to seven domains: concerns about loved-ones; symptom management and care (including team competence, goals of care discussions); spiritual, religious, and existential preoccupations (including regrets, meaning, hope and trust); being oneself (including fear of isolation and of being a burden, absence of hope, and personhood); the need for comforting experiences and pleasure; dying and death (covering emotional and practical concerns); and after death preoccupations.

CONCLUSION

This list of 15 concerns may prove valuable for clinicians as a tool for improving communication and support to better meet the needs of patients at high risk of dying.

Intervention and coping strategies for self-perceived burden of patients with cancer: A systematic review

Objective

Self-perceived burden (SPB) is a painful experience for patients with cancer and their caregivers. However, the intervention and coping strategies for SPB have not been systematically summarized. This work reviews the effects of interventions and coping strategies on SPB.

Methods

A systematic search, including trawling through six electronic databases, was performed to identify the articles published from January 2003 to February 2023, both in English and in Chinese. The key terms related to burden on others, intervention, and coping of patients with cancer were adopted. Manual search was also applied.

Results

Thirty articles were identified. Interventions were presented in three dimensions: physical, psychological, and financial/family. Coping strategies were presented in terms of coping attitudes and behaviors. Interventions such as functional exercise and psychological adjustment can improve SPB in the three dimensions mentioned above and thus alleviate SPB. Patients with different coping styles have different implications for prognosis. In addition, the impact of caregivers on patients and the coping they provided were worthy of attention.

Conclusions

This article reviewed interventions for SPB in patients with cancer and the coping strategies from patients and caregivers. The interventions targeting on SPB can alleviate SPB by improving patients' physical condition, psychological status, and financial/family situation. However, the coping attitudes and behaviors of both patients and caregivers were depending on the individual cognitions and perceptions; different coping strategies produced different outcomes. To achieve improvements in SPB, interventions should incorporate the coping strategies. Appropriate patient-caregiver dyad interventions should be constructed based on the commonalities in coping with SPB.

Self-perceived Burden for People With Life-threatening Illness: A Qualitative Systematic Review

CONTEXT

The perception of being a burden to others is a significant concern for people with life-threatening illness. It is unclear what underpins the concept of "self-perceived burden".

OBJECTIVES

To appraise and integrate primary evidence underpinning the concept of self-perceived burden (SPB) with respect to their informal caregivers among adult patients with life-threatening illness.

METHODS

This is a systematic review and a thematic synthesis of qualitative primary data. MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science were searched in September 2021, supplemented by hand searching of textbooks and web search engines, peer-review journals, and contact with experts. Qualitative studies were included if they provided primary data of adult patients' (with life-limiting illness) SPB toward their informal caregivers. Studies were appraised using the Critical Appraisal Skills Programme checklist.

RESULTS

Nine studies were included, reporting on 219 patients who mostly had advanced life-threatening illness and needed physical assistance for daily activities. SPB is a highly subjective perception contrasting self and/or informal caregivers in the past, present, and future. Patients develop SPB feeling uncertain about caregivers' perceptions and increasing future burden. SPB interacts with other factors of surrounding complex balances (such as care needs, reality, and identity) which would change over time, and patients' reactions to SPB at the sacrifice of their wishes may conversely increase the total suffering.

CONCLUSION

SPB is not a static perception but a fluctuating and complex 'process' based on uncertainty. More diverse understandings and following interventions to achieve a better balance of care should be sought.

Prevalence and factors of discordance attitudes toward advance care planning between older patients and their family members in the primary medical and healthcare institution

Background

This study aimed at investigating the prevalence and factors of the discordant attitudes toward advance care planning (ACP) among older patients and their family members toward patients' engagement in ACP in the primary medical and healthcare institution.

Methods

In a cross-sectional study, a total of 117 older patients and 117 family members from Jinhua Fifth Hospital in China were enrolled. The questionnaire included sociodemographic characteristics, functional capacity assessment, and attitudes toward patients' engagement in ACP. Functional capacity assessment scales included the Modified Barthel Index (MBI), the Short-Form Mini-Nutritional Assessment (MNA-SF), the 15-item Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination (MMSE), the Clinical Frailty Scale (CFS), and the SARC-F questionnaire.

Results

The discordance attitudes toward patients' engagement in ACP between patients and family members accounted for 41(35.0%). In the multivariate logistic analysis, factors associated with higher odds of discordance attitudes toward patients' engagement in ACP included greater age differences between patients and family members (OR = 1.043, 95% CI: 1.007-1.081), lower educational level for family members (OR = 3.373, 95% CI: 1.239-9.181), the patient's higher GDS-15 score (OR = 1.437, 95% CI: 1.185-1.742), and patient's higher MNA-SF score (OR = 1.754, 95% CI: 1.316-2.338).

Conclusion

Older patients and their family members had little ACP knowledge, and factors that influence discordance attitudes toward patients' engagement in ACP included the age gaps between patients and family members, family members' educational level, patients' depressive symptoms, and patients' nutritional status.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

Suicidal/self-harm behaviors among cancer patients: a population-based competing risk analysis

BACKGROUND

Cancer patients had elevated risk of suicidality. However, few researches studied the risk/protective factors of suicidal/self-harm behaviors considering the competing risk of death. The objective of this study is to systematically investigate the risk of suicidal/self-harm behaviors among Hong Kong cancer patients as well as the contributing factors.

METHODS

Patients aged 10 or above who received their first cancer-related hospital admission (2002-2009) were identified and their inpatient medical records were retrieved. They were followed for 365 days for suicidal/self-harm behaviors or death. Cancer-related information and prior 2-year physical and psychiatric comorbidities were also identified. Competing risk models were performed to explore the cumulative incidence of suicidal/self-harm behavior within 1 year as well as its contributing factors. The analyses were also stratified by age and gender.

RESULTS

In total, 152 061 cancer patients were included in the analyses. The cumulative incidence of suicidal/self-harm behaviors within 1 year was 717.48/100 000 person-years. Overall, cancer severity, a history of suicidal/self-harm behaviors, diabetes and hypertension were related to the risk of suicidal/self-harm behaviors. There was a U-shaped association between age and suicidal/self-harm behaviors with a turning point at 58. Previous psychiatric comorbidities were not related to the risk of suicidal/self-harm behaviors. The stratified analyses confirmed that the impact of contributing factors varied by age and gender.

CONCLUSIONS

Cancer patients were at risk of suicidal/self-harm behaviors, and the impacts of related factors varied by patients' characteristics. Effective suicide prevention for cancer patients should consider the influence of disease progress and the differences in age and gender.

Dimensions of end-of-life preferences in the Swiss general population aged 55+

BACKGROUND

understanding end-of-life preferences in the general population and how they are structured in people's minds is essential to inform how to better shape healthcare services in accordance with population expectations for their end of life and optimise communication on end-of-life care issues.

OBJECTIVE

explore key dimensions underlying end-of-life preferences in a nationally representative sample of adults aged 55 and over in Switzerland.

METHODS

respondents (n = 2,514) to the Swiss version of the Survey of Health, Ageing and Retirement in Europe assessed the importance of 23 end-of-life items on a 4-point Likert scale. The factorial structure of the underlying end-of-life preferences was examined using exploratory structural equation modelling.

RESULTS

four dimensions underlying end-of-life preferences were identified: a medical dimension including aspects related to pain management and the maintenance of physical and cognitive abilities; a psychosocial dimension encompassing aspects related to social and spiritual support; a control dimension addressing the need to achieve some control and to put things in order before death; and a burden dimension reflecting wishes not to be a burden to others and to feel useful to others.

CONCLUSION

highlighting the multi-dimensionality of end-of-life preferences, our results reaffirm the importance of a holistic and comprehensive approach to the end of life. Our results also provide a general framework that may guide the development of information and awareness campaigns on end-of-life care issues in the general population, informational materials and guidelines to support healthy individuals in end-of-life thinking and planning, and advance directive templates appropriate for healthy individuals.

Conflicting views during gynecologic cancer care: a comparison of patients' and caregivers' perceptions of burden

This study describes the experiences of cancer caregivers and compares these experiences with patients' assessment of cancer's toll on their caregiver. Participants (16 patient-caregiver dyads) were recruited from a NCI cancer center of excellence in the northeastern United States. Patients were in treatment for ovarian (n = 7), uterine (n = 2), or endometrial (n = 7) cancers. Caregivers included 7 women and 9 men who described themselves as spouse/partner (n = 7), adult child (n = 4), sister (n = 2), parent (n = 1), nephew (n = 1), and friend (n = 1). Participants completed semi-structured individual interviews that focused on perceptions of caregiver burden or the impact of the patient's diagnosis on the caregiver specifically. Data were coded inductively to identify themes present within participants' responses. This process included open and axial coding. Two overarching themes emerged: (1) patient-caregiver agreement and (2) patient-caregiver disagreement. Patient-caregiver agreement included two subthemes: (1) weight gain and (2) weight loss. Patient-caregiver disagreement consisted of two subthemes: (1) differing perspectives of quantity and quality of caregiving provided and (2) withholding of caregiver concerns. Overall, there was 56% agreement between patient and caregiver responses. The results may inform intervention development to address patient-caregiver communication, cancer caregiver needs, and ultimately improve caregiver quality of life.

Depressive rumination and life satisfaction among institution-dwelling Chinese older adults: the roles of perceived burdensomeness and social support from individuals within the institution

Objectives: We examined how institution-dwelling older adults' depressive rumination was associated with their life satisfaction by taking perceived burdensomeness as a mediator and social support from individuals within the institution (SSII) as a moderator.Method: A total of 194 older adults from 24 institutions in four provinces of China completed a questionnaire survey.Results: Depressive rumination was negatively associated with life satisfaction, and perceived burdensomeness mediated this association. Moreover, SSII moderated the indirect association between depressive rumination and life satisfaction through perceived burdensomeness. Specifically, depressive rumination had a negative effect on life satisfaction through perceived burdensomeness only for older adults with less SSII.Conclusion: Our study indicated that depressive rumination could damage older adults' life satisfaction by increasing their perceived burdensomeness. Fortunately, older adults' perception of social support from individuals within the institution could attenuate this negative effect. This study has implications for designing intervention programs to improve the institution-dwelling older adults' life satisfaction.

Solidarity and suffering: enrolled terminal patients’ and their caregiver’s experiences of the community-based palliative care programme in an urban slum of Bangladesh

Background:

Palliative care has been recognised as a global health challenge. Although accessibility has increased, there is little recognition of the importance of palliative care in low- and middle-income countries. In Bangladesh, institutional palliative care is not accessible due to a lack of awareness, financial constraints, and fewer facilities. Hence, there needs to be a better understanding of providing and improving existing community-based palliative care. For this, it is essential to understand the experiences of patients and their caregivers who require palliative care. With this aim, this study explores the experiences of palliative patients and their primary caregivers enrolled in a palliative care project, ‘Momotamoy Korail’ run by Bangabandhu Sheikh Mujib Medical University in an urban slum, Dhaka.

Methods:

This research is a part of a larger qualitative study that relied on a focused ethnographic approach. For this study, we used 19 in-depth interviews following a semi-structured guideline with the palliative care patients and their primary caregivers enrolled in the community-based palliative care project.

Results:

Mostly women (wives and daughters-in-law) are the primary caregivers in a family. Therefore, male patients are more likely to receive family care than female patients. Both male and female patients expressed the desire for a death free of suffering. All patients felt lonely and socially abandoned with a perception of being a burden to their families. Despite the diversity in physical, social, psychological, and financial suffering, patients and caregivers were optimistic towards a healthy life free of illness. All respondents were satisfied with the care they received from the palliative care assistants, which provide them hope and dignity for life.

Conclusion:

Experiences of the respondents can improve the quality of the existing community-based palliative care services and add great value to the discipline of palliative care in public health. The findings provided an understanding of what would be required to extend community-based palliative care to other healthcare settings. More awareness through community mobilisation about the need for and benefit of palliative care is needed to make it sustainable.

Mitigating End-of-Life Burden: Parallel Perspectives of Physician-Patients & Family Caregivers

CONTEXT

Patients and family caregivers perceive burden in care at the end of life differently even when the patient is a physican.

OBJECTIVES

We describe how older adult physicians as prospective patients (hereafter "physician-patients") and family caregivers of physician-patients view burden in care at the end of life.

METHODS

Interviews with physician-patients (n = 28) and family caregivers (n = 26) of physician-patients who had died were conducted as part of a shared decision-making study. Both groups expressed concerns with burden at the end of life. We coded and analyzed descriptions of burden using inductive and deductive approaches to coding sub-themes as in qualitative description. We then created a conceptual model depicting the relationships among the concepts, returning to the interviews to verify respective contexts.

RESULTS

Unilateral actions taken at different points in the illness trajectory by both groups suggested different concerns about burden occurring in parallel. While everyone anticipated burden associated with care at the end of life, physician-patients made legal and financial arrangements to minimize this burden. Nevertheless several family caregivers described the burden that they experienced. We propose a conceptual model to guide future research and care.

CONCLUSION

Physician-Patients ' clinical insights drive their attempts to alleviate burden on their families. However, family caregivers still experienced burden. Recognizing the parallel perspectives of burden may inform the type and timing of interventions to effectively minimize burden and provide compassionate care to both patients and families at the end of life.

Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review

Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.

Preferred life expectancy and the association with hypothetical adverse life scenarios among Norwegians aged 60

BACKGROUND

how long older individuals prefer to live given hypothetical adverse changes in health and living conditions has been insufficiently studied.

OBJECTIVES

the objective of this study is to investigate the relationship between six adverse health and living conditions and preferred life expectancy (PLE) after the age of 60 years.

DESIGN

cross-sectional face-to-face interviews.

SETTING

population-based sample.

PARTICIPANTS

825 community dwellers aged 60 years and older in Norway.

METHODS

logistic regression models were used to analyse PLE, measured with a single question: 'If you could choose freely, until what age would you wish to live?' The impact on PLE of several hypothetical scenarios, such as being diagnosed with dementia, spousal death, becoming a burden, poverty, loneliness and chronic pain was analysed by age, sex, education, marital status, cognitive function, self-reported loneliness and chronic pain.

RESULTS

average PLE was 91.4 years (95% CI 90.9, 92.0), and there was no difference between men and women, but those at older ages had higher PLE than those at younger ages. The scenarios that had the strongest negative effects on PLE were dementia, followed by chronic pain, being a burden to society, loneliness, poverty and losing one's spouse. PLE among singles was not affected by the prospect of feeling lonely. The higher educated had lower PLE for dementia and chronic pain.

CONCLUSION

among Norwegians 60+, the desire to live into advanced ages is significantly reduced by hypothetical adverse life scenarios, with the strongest effect caused by dementia and chronic pain.

Awareness and attitudes towards advance care planning in primary care: role of demographic, socioeconomic and religiosity factors in a cross-sectional Lebanese study

OBJECTIVE

To assess awareness and attitudes towards engaging in advance care planning (ACP) and their relationship with demographic, socioeconomic and religiosity factors among Lebanese middle-aged to older-aged adults in primary care.

DESIGN

A cross-sectional survey study.

SETTING

Tertiary referral hospital in Beirut, Lebanon.

PARTICIPANTS

A total of 215 middle-aged to older-aged adults.

RESULTS

Out of 215 participants, 18.6% of participants knew about ACP; 94% favoured truth-telling; 87.4% favoured healthcare autonomy; 77.2% favoured documenting their own health values and preferences; and 29.3% were willing to undergo life-prolonging interventions. Among participants who were aware of ACP, 67.5% preferred ACP documentation and 85% had negative attitudes towards life-sustaining interventions. Women were more aware about ACP than men. Those who were willing to undergo life-prolonging interventions were found to be men and had higher religiosity scores.

CONCLUSION

Large deficit in ACP awareness was evident despite the high preference for healthcare autonomy. Medical and public health efforts should strive to enhance patients' ACP awareness and engagement in ACP while considering factors relevant to gender, culture and religiosity.

Exploring dyadic management of nutrition care throughout and beyond head and neck cancer treatment

AIMS AND OBJECTIVES

To identify how patients and carers collaborate to manage nutrition care throughout and beyond head and neck cancer (HNC) treatment as a step towards identifying changes to service delivery that are inclusive of the needs of the patient-carer dyad.

BACKGROUND

Research in the field of dyadic interventions in cancer care is emerging, and there has been little work exploring patient-carer dyad needs in the provision of nutrition care in HNC.

DESIGN

A qualitative study design was used.

METHODS

Narrative interviews were completed with 13 patients and 15 carers over a 12-month period (prior to treatment commencing, and 2 weeks, 3 months and 12 months post-treatment completion). Deductive analysis of interview transcripts was performed using directed content analysis guided by the Theory of Dyadic Illness Management (TDIM). COREQ guidelines were used.

RESULTS

Seven themes across four TDIM constructs were identified: (1) understanding and adapting to physical challenges impacting nutrition intake, (2) adjusting to emotional impact of changes to eating and drinking, (3) providing practical support, (4) intrapersonal characteristics, (5) interpersonal characteristics, (6) healthcare culture and (7) managing carer burnout.

CONCLUSION

This study highlights the importance of healthcare professionals recognising the patient and carer dyad as a team to enhance engagement in nutrition care and to ensure that their physical and psychological support needs across the cancer continuum are met.

RELEVANCE TO CLINICAL PRACTICE

It is important that healthcare professionals understand information and support needs and preferences within patient-carer dyads prior to HNC treatment commencing and adapt care and interventions based on their changing needs throughout and beyond the treatment period.

The tension between carrying a burden and feeling like a burden: a qualitative study of informal caregivers' and care recipients' experiences after patient discharge from hospital

Purpose: The number of people aged 80 and above is projected to triple over the next 30 years. Expanding public expenditure on long-term care servicesHas made policies encouraged informal caregiving. Burden of care describes challenges connected to informal caregiving. Dependent patients report feelings of being a burden. Few studies have focused on both the experience of caregiver burden and recipients' feelings of burden. This study explore the experiences of old patients and informal caregivers in the first 30 days after the patient's discharge. Method: Aphenomenological approach was used to explore the subjective experiences of the participants . Semi-structured individual interviews were analysed thematically. Results: The reults reflect imbalance regarding care needs relative to time, social roles, physical and emotional states, and formal care resources. Four themes emerged from the interviews: 1) Bridging the gap, 2) Family is family, 3) Never enough, and 4) Stress and distress. Conclusions: The participants face strains within their roles. The care situation has potential to be burdensome. To secure healthcare quality for old patients, the informal carer's role needs to be recognized. Informal care based on altruism and reciprocity seems to be positive, whereas informal care based on family norms might have a negative impact.

Self-perceived burden and influencing factors in patients with cervical cancer administered with radiotherapy

BACKGROUND

Cervical cancer is the fourth commonest malignancy in women around the world. It represents the second most commonly diagnosed cancer in South East Asian women, and an important cancer death cause in women of developing nations. Data collected in 2018 revealed 5690000 cervical cancer cases worldwide, 85% of which occurred in developing countries.

AIM

To assess self-perceived burden (SPB) and related influencing factors in cervical cancer patients undergoing radiotherapy.

METHODS

Patients were prospectively included by convenient sampling at The Fifth Affiliated Hospital of Sun Yat-Sen University, China between March 2018 and March 2019. The survey was completed using a self-designed general information questionnaire, the SPB scale for cancer patients, and the self-care self-efficacy scale, Strategies Used by People to Promote Health, which were delivered to patients with cervical cancer undergoing radiotherapy. Measurement data are expressed as the mean ± SD. Enumeration data are expressed as frequencies or percentages. Caregivers were the spouse, offspring, and other in 46.4, 40.9, and 12.7%, respectively, and the majority were male (59.1%). As for pathological type, 90 and 20 cases had squamous and adenocarcinoma/adenosquamous carcinomas, respectively. Stage IV disease was found in 12 (10.9%) patients.

RESULTS

A total of 115 questionnaires were released, and five patients were excluded for too long evaluation time (n = 2) and the inability to confirm the questionnaire contents (n = 3). Finally, a total of 110 questionnaires were collected. They were aged 31-79 years, with the 40-59 age group being most represented (65.4% of all cases). Most patients were married (91.8%) and an overwhelming number had no religion (92.7%). Total SPB score was 43.13 ± 16.65. SPB was associated with the place of residence, monthly family income, payment method, transfer status, the presence of radiotherapy complications, and the presence of pain (P < 0.05). The SPB and self-care self-efficacy were negatively correlated (P < 0.01). In multivariate analysis, self-care self-efficacy, place of residence, monthly family income, payment method, degree of radiation dermatitis, and radiation proctitis were influencing factors of SPB (P < 0.05).

CONCLUSION

Patients with cervical cancer undergoing radiotherapy often have SPB. Self-care self-efficacy scale, place of residence, monthly family income, payment method, and radiation dermatitis and proctitis are factors independently influencing SPB.

Adapting a whole health model to home-based primary care: Bridging person-driven priorities with veteran and family-centered geriatric care

Through the integration of Whole Health for Life into the Department of Veterans Affairs (VA) health care system, the VA aims to transform health care delivery from a disease management approach to one that embraces person-centered care. The home-based primary care (HBPC) program is a care model that, within the VA, provides holistic primary care services to homebound veterans with multiple chronic medical conditions, mental health issues, and functional declines. These veterans may have limited access to VA programs delivered in a traditional outpatient format. This article describes adaptations to the whole health model of care that could improve its accessibility and applicability to HBPC veterans, caregivers, and the interdisciplinary teams that serve this population. These modifications are informed by whole-person geriatric and gerontological and family-systems theories and address population-based differences in the focus and approach to care. The focus on care is expanded to (a) reflect the importance of attending to caregiver needs and well-being and (b) shift from a preventative model to one that prioritizes resilience and maintenance. The approach to care emphasizes alternative modes of delivery, adaptations to interventions, and integration of geriatric-specific medical considerations into the self-care domains and more directly centers the collaboration between family, the VA, and community partners. This adapted model also addresses the unique needs of health care teams providing in-home services to medically complex veterans and offers suggestions for enhancing self-care and preventing burnout. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Views on a "Good Death": End-of-Life Preferences and Their Association With Socio-Demographic Characteristics in a Representative Sample of Older Adults in Switzerland

The current study explores the end-of-life (EOL) preferences of a national representative sample of adults aged 55 and older in Switzerland and shows how these preferences vary by respondents' sociodemographic characteristics and the linguistic region in which they live. Many of the presented EOL attributes are considered as (very) important by a large majority of the older population in Switzerland with significant variations across sociodemographic groups. Specifically, gender is related to psychosocial aspects of EOL, age to the importance attached to avoiding being a burden on the society, and education levels to preferences regarding overtreatment and advance care planning. The results highlight the importance of a personalized, holistic and interdisciplinary approach to EOL and EOL care, since social, psychological, organizational and physical aspects of EOL are rated as (very) important with significant differences in EOL preferences across sociodemographic groups.

Self-perceived burden and its associations with health-related quality of life among urologic cancer patients

OBJECTIVE

This study examined the prevalence of self-perceived burden (SPB) and its association with health-related quality of life (HRQoL) among urologic cancer patients.

METHODS

This was a prospective, cross-sectional study. A total of 429 respondents diagnosed with urologic cancers (prostate, bladder and renal cancer) from Sarawak General Hospital and Subang Jaya Medical Centre in Malaysia were interviewed by using a structured questionnaire. SPB and HRQoL were measured by the Self-perceived Burden Scale and the Functional Assessment of Cancer Therapy-General 7 Item Scale respectively.

RESULTS AND CONCLUSION

Self-perceived burden was experienced by 73.2% of the respondents. Respondents who had a lower education level, a monthly household income <MYR 5,000, monthly household expenditures <MYR 3,000 or whose Eastern Cooperative Oncology Group performance status (ECOG-PS) rating was higher and who faced medium to high subjective financial toxicity (FT) were more likely to experience low HRQoL, but not SPB, after adjustment for covariates. As medium to high subjective FT is significantly associated with high SPB and low HRQoL, future interventions should be prioritised to address subjective FT, which, in turn, would reduce SPB and improve HRQoL.

Self-management of patients with advanced cancer: A systematic review of experiences and attitudes

BACKGROUND

Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention.

AIM

To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management.

DESIGN

A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting.

DATA SOURCES

MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019).

RESULTS

Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles).

CONCLUSION

Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals.

Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention. Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI). Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness. Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

End-of-Life Activities Among Community-Dwelling Older Adults in Japan

This study explored end-of-life (EOL) activities among community-dwelling Japanese older adults and the relationships between EOL activities and related variables. One hundred twenty-three older adults (38 men, 87 women; mean age = 72.54 years) who attended EOL seminars were surveyed regarding EOL activities, attitudes toward death, and mental health status. Cluster analysis of EOL activities revealed three clusters: Planning (e.g., had planned own funeral arrangements), Preference (e.g., had talked about EOL care with their family), and Preparation (e.g., already written their will). The number of EOL-related events attended was positively correlated with Preparation, while fear of death was negatively associated with Preference. Older adults with bereavement experience had higher Planning and Preparation scores than those without such experience.

Self-Perceived Burden to Others: Patient and Family Caregiver Correlates

Aims

To provide further evidence about the prevalence and correlates of the sense of “self-perceived burden” (SPB) to others, and to examine its association with caregiver reports of burden.

Methods

The participants were 65 patients with advanced cancer and their family caregivers. Patients completed measures of SPB and family members completed a caregiver burden scale.

Results

SPB was experienced at minimal to mild levels by 35% of patients, and at moderate to extreme levels by another 28%. It was correlated with some physical symptoms, but more frequently with psychological symptoms. The family members of patients who reported that SPB was a significant problem had higher scores on the caregiver burden scale than family members of other patients (p=0.048), although the overall correlation was modest.

Conclusions

SPB is a common and distressing concern for many patients receiving palliative care and is associated with a number of other distressing concerns.

The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review

BACKGROUND

Family members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry.

METHODS

A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies.

RESULTS

Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families' experiences and grief after EAS. 4) Family and 'the good euthanasia death' according to Dutch physicians.

CONCLUSION

Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.

Self-perceived burden mediates the relationship between self-stigma and quality of life among Chinese American breast cancer survivors

PURPOSE

Cancer-related self-stigma (the internalized sense of shame about having cancer) has been found to associate with poorer quality of life (QoL) among cancer survivors. However, culturally salient illness beliefs (e.g., cancer is contagious; cancer is a result of karma; and cancer brings shame to the family) may make Chinese cancer survivors vulnerable to self-stigmatization. This study examined the association between self-stigma and QoL among Chinese American breast cancer survivors (BCS). To understand the potential mechanism, the mediating role of self-perceived burden to caregivers between self-stigma and QoL was also examined.

METHODS

Chinese American BCS (n = 136) were recruited through community-based cancer associations. Participants' self-stigma, self-perceived burden, and QoL were measured in a questionnaire package.

RESULTS

Structural equation modeling results supported the proposed mediation model in predicting physical QoL (χ²(100) = 123.041, CFI = 0.982, TLI = 0.975, RMSEA = 0.041) and emotional QoL (χ²(84) = 137.277, CFI = 0.958, TLI = 0.940, RMSEA = 0.069), with satisfactory model fit indices. Both the indirect effects from self-stigma to QoL via self-perceived burden (physical: β = - 0.13; 95% CI = - 0.22, - 0.07 and emotional: β = - 0.11; 95% CI = - 0.22, - 0.04) and the direct effects from self-stigma to poorer QoL were significant (physical: β = - 0.22; 95% CI = -0.34, -0.10 and emotional: β = - 0.39; 95% CI = - 0.54, - 0.23), suggesting a partial mediation effect of self-perceived burden between self-stigma and QoL.

CONCLUSIONS

Self-stigma could reduce physical and emotional QoL through increasing self-perceived burden. Interventions aiming to reduce Chinese American BCS' self-stigma and perceptions of burdensomeness may facilitate improvement in QoL, which in turn promotes better cancer survivorship.

Associations between Japanese People's Concern about Family Caregiver Burden and Preference for End-Of-Life Care Location

Through a cross-sectional nationwide survey, this study identified the associations between Japanese people's choice of end-of-life care location and their sense of being a burden or a source of concern to their family members. A total of 1,042 people responded to the survey (a response rate of 55 percent). Of these, 44 percent said they would prefer to receive end-of-life care at home, 15 percent in hospital, 19 percent in a palliative care unit, 10 percent in a public nursing home, and 2 percent in a private nursing home. Multinomial logistic regression analysis revealed that those who thought it most important to relieve caregiver burden on family members tended to prefer a palliative care unit or a public nursing home to their own homes; those who were most concerned about the effect their death would have on their family members tended to prefer a hospital or a palliative care unit to their own homes. These findings may assist in the development of a more effective end-of-life care system in Japan and in other countries.

It's okay to talk about death: Exploring the end-of-life wishes of healthy young adults

Young adults (N = 80) participated in advance care planning (ACP) as part of a death and dying course and submitted reflection papers on their experiences. These papers were analyzed using directed qualitative content analysis methods. Among the findings, participants almost exclusively chose a parent or other family member as a Health Care Agent. Twenty-five percent expressed concern about placing burden on their agent, but felt their advance directives (AD) would ease that burden. For many, previous experiences with death helped shape their wishes. This research has practice implications for recruiting more healthy young adults in completing their AD.

Advanced Cancer Patients’ Perceptions of Dignity

Purpose:

The present study assesses the relationship between patient dignity in advanced cancer and the following variables: psychological distress, preparatory grief, and sociodemographic and clinical characteristics.

Methods:

The sample consisted of 120 patients with advanced cancer. The self-administered questionnaires were as follows: the Preparatory Grief in Advanced Cancer Patients (PGAC), the Patient Dignity Inventory–Greek (PDI-Gr), the Greek Schedule for Attitudes toward Hastened Death (G-SAHD), and the Greek version of the Hospital Anxiety and Depression Scale (G-HADS).

Results:

Moderate to strong statistically significant correlations were found between the 4 subscales of PDI-Gr (psychological distress, body image and role identity, self-esteem, and social support) with G-HADS, G-SAHD, and PGAC ( P < .005), while physical distress and dependency was moderately correlated with depression. Multifactorial analyses showed that preparatory grief, depression, and age influenced psychological distress, while preparatory grief, depression, and performance status influenced body image and role identity.

Conclusions:

Preparatory grief, psychological distress, and physical symptoms had significant associations with perceptions of dignity among patients with advanced cancer. Clinicians should assess and attend to dignity-distressing factors in the care of patients with advanced cancer.

Impacts on employment, finances, and lifestyle for working age people facing an expected premature death: A systematic review

Objective:

The working ages (25–65 years) are a period when most people have significant work, financial, and family responsibilities. A small proportion of working age people will face an expected premature death from cancer or other life-limiting illness. Understanding the impact an expected premature death has on this population is important for informing support. The current study set out to summarize research describing the effects that facing an expected premature death has on employment, financial, and lifestyle of working age people and their families.

Method:

A systematic review using narrative synthesis approach. Four electronic databases were searched in July 2016 for peer-reviewed, English language studies focusing on the financial, employment, and lifestyle concerns of working age adults living with an advanced life-limiting illness and/or their carers and/or children.

Results:

Fifteen quantitative and 12 qualitative studies were included. Two-thirds (n = 18) were focused on cancer. All studies identified adverse effects on workforce participation, finances, and lifestyle. Many patients were forced to work less or give up work/retire early because of symptoms and reduced functioning. In addition to treatment costs, patients and families were also faced with child care, travel, and home/car modification costs. Being younger was associated with greater employment and financial burden, whereas having children was associated with lower functional well-being. Changes in family roles were identified as challenging regardless of diagnosis, whereas maintaining normalcy and creating stability was seen as a priority by parents with advanced cancer. This review is limited by the smaller number of studies focussing on the needs of working age people with nonmalignant disease.

Significance of results:

Working age people facing an expected premature death and their families have significant unmet financial, employment, and lifestyle needs. Comparing and contrasting their severity, timing, and priority for people with nonmalignant conditions is required to better understand their unique needs.

End of life care preferences among people of advanced age: LiLACS NZ

BACKGROUND

Understanding end of life preferences amongst the oldest old is crucial to informing appropriate palliative and end of life care internationally. However, little has been reported in the academic literature about the end of life preferences of people in advanced age, particularly the preferences of indigenous older people, including New Zealand Māori.

METHODS

Data on end of life preferences were gathered from 147 Māori (aged >80 years) and 291 non- Māori aged (>85 years), during three waves of Te Puawaitangi O Nga Tapuwae Kia Ora Tonu, Life and Living in Advanced Age (LiLACs NZ). An interviewer-led questionnaire using standardised tools and including Māori specific subsections was used.

RESULTS

The top priority for both Māori and non-Māori participants at end of life was 'not being a burden to my family'. Interestingly, a home death was not a high priority for either group. End of life preferences differed by gender, however these differences were culturally contingent. More female Māori participants wanted spiritual practices at end of life than male Māori participants. More male non-Māori participants wanted to be resuscitated than female non- Māori participants.

CONCLUSIONS

That a home death was not in the top three end of life priorities for our participants is not consistent with palliative care policy in most developed countries where place of death, and particularly home death, is a central concern. Conversely our participants' top concern - namely not being a burden - has received little research or policy attention. Our results also indicate a need to pay attention to diversity in end of life preferences amongst people of advanced age, as well as the socio-cultural context within which preferences are formulated.

Factors influencing attitudes toward advance directives in Korean older adults

AIM

We aimed to determine the factors influencing attitudes toward advance directives in Korean older adults with consideration of an Asian cultural background.

METHODS

We recruited community-dwelling older adults aged 60 years or older at a regional senior welfare center in Korea. Demographic factors and mental and physical health status were examined using questionnaires and a physical examination. The questionnaire also assessed perceived necessity of advance directives and related experiences.

RESULTS

Most participants (79.32%) agreed that advance directives were necessary. Older adults with high education levels (odds ratio [OR] 2.31, 95% confidence interval [CI] 0.84-6.34), low economic status (OR 2.09, 95% C.I. 0.60-7.27), and poor cognitive function (adjusted odds ratio [aOR] 2.10, 95% CI 0.89-4.97) had a greater odds of agreeing that advance directives are necessary. All participants with self-care problems (9/9) and most participants with at risk status of physical functioning (13/14) reported agreement. Death-related experiences were also associated. Notably, individuals who had discussions on end-of-life care with family members showed a greater odds of agreeing that advance directives are necessary (aOR 2.12, 95% CI 0.88-5.11).

CONCLUSIONS

The factors associated with increased agreement that advance directives are necessary were high education level, low economic status, poor cognitive function, problems in self-care, poor physical functioning, death-related experiences. Especially, discussions of end-of-life care with family members increased the agreement. Thus, discussion on end-of-life care should be encouraged and the factors influencing older adults' attitudes toward advance directives should be considered in developing policies for such discussion.

Self-perceived burden, perceived burdensomeness, and suicidal ideation in patients with chronic pain

Background: Self-perceived burden and perceived burdensomeness are two apparently related constructs that have arisen independently from research in physical and mental health, respectively. Although both are associated with suicidal ideation in individuals with chronic pain, they have yet to be examined concurrently in the same group of patients.

Aims: The aim of this study was to investigate the relationship between the two constructs and their differential prediction of suicidal ideation.

Methods: Participants were 260 outpatients of an interdisciplinary chronic pain treatment program. Each participant completed the Self-Perceived Burden Scale (SPBS), the Interpersonal Needs Questionnaire Perceived Burdensomeness Scale (INQPBS), the Beck Scale for Suicide Ideation, and the thoughts of self-harm item of the Patient Health Questionnaire-9.

Results: The SPBS and the INQPBS were both unifactorial measures with good internal consistency. They correlated significantly with one another (r = 0.50, P < 0.001), as well as with scores on the two measures of suicidal ideation (rs ranging from 0.29 to 0.62, Ps < 0.001). However, the INQPBS correlated more highly with suicidal ideation than did the SPBS. In regression analyses, the INQPBS predicted unique variance in suicidal ideation after adjusting for the SPBS. Conversely, the SPBS did not contribute uniquely when the INQPBS was entered first.

Conclusions: Patients with chronic pain who believe that they have become “a burden to others” are at increased risk for suicidal ideation. The conceptual similarities and differences between the constructs of self-perceived burden and perceived burdensomeness are reviewed to explain why perceived burdensomeness is the stronger predictor of this increased risk.

Suffering and dying well: on the proper aim of palliative care

In recent years a large empirical literature has appeared on suffering at the end of life. In this literature it is recognized that suffering has existential and social dimensions in addition to physical and psychological ones. The non-physical aspects of suffering, however, are still understood as pathological symptoms, to be reduced by therapeutical interventions as much as possible. But suffering itself and the negative emotional states it consists of are intentional states of mind which, as such, make cognitive claims: they are more or less appropriate responses to the actual circumstances of the patient. These circumstances often are such that it would rather be a pathological symptom not to be sad and not to suffer. Suffering, therefore, is sometimes and to some extent a condition to be respected. Although I do not dispute that the alleviation of suffering is the main aim of palliative care, in pursuing that aim we should acknowledge a constraint of realism.

A Patient with Cancer and Her Family in Caring Partnership Based on Margaret Newman's Theory of Health as Expanding Consciousness

The purpose, on the basis of Margaret Newman's theory of health as expanding consciousness in a unitary perspective, was to practice the caring partnership with a client who could not share their desires and find their future direction at a gear change period and document the process of their relational changes within this process. The design was research as praxis. The participant was a patient with cancer and her family in the midst of a difficult health situation. Through caring partnership, a nurse researcher asked to tell "the meaningful events and relationships in their lives" over four in-depth dialogue meetings. Data were collected from the tape-recorded dialogue transcriptions. In the process of caring partnership, the patient and each family member recognized their own pattern and family pattern of "being closed off," their approach to the situation, and found a new direction through this process. The finding suggested that caring partnership as a nursing intervention would be helpful for nurses as well as for patients and their families in difficult health situations.

A scoping research literature review to assess the state of existing evidence on the “bad” death

Objective:

A scoping research literature review on “bad death” was undertaken to assess the overall state of the science on this topic and to determine what evidence exists on how often bad deaths occur, what contributes to or causes a bad death, and what the outcomes and consequences of bad deaths are.

Method:

A search for English-language research articles was conducted in late 2016, with 25 articles identified and all retained for examination, as is expected with scoping reviews.

Results:

Only 3 of the 25 articles provided incidence information, specifying that 7.8 to 23% of deaths were bad and that bad deaths were more likely to occur in hospitals than in community-care settings. Many different factors were associated with bad deaths, with unrelieved pain being the most commonly identified. Half of the studies provided information on the possible consequences or outcomes of bad deaths, such as palliative care not being initiated, interpersonal and team conflict, and long-lasting negative community effects.

Significance of results:

This review identified a relatively small number of research articles that focused in whole or in part on bad deaths. Although the reasons why people consider a death to be bad may be highly individualized and yet also socioculturally based, unrelieved pain is a commonly held reason for bad deaths. Although bad and good deaths may have some opposing causative factors, this literature review revealed some salient bad death attributes, ones that could be avoided to prevent bad deaths from occurring. A routine assessment to allow planning so as to avoid bad deaths and enhance the probability of good deaths is suggested.