Review: a narrative review of the published ethical debates in palliative care research and an assessment of their adequacy to inform research governance

Family experiences with non-therapeutic research on dying patients in the intensive care unit

Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient.We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care.Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients' lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval.Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed.

Palliative care organization and staffing models in residential hospices: Which makes the difference?

BACKGROUND

The number of patients using palliative care services, particularly residential hospices, is increasing. Policymakers are urging these services to reflect on the most effective organizational strategies for meeting patients' complex care needs.

AIM

To analyze the predictive power of staffing, structure and process indicators towards optimal control of patients' clinically significant symptoms over time.

DESIGN

Secondary analysis of data from a multicentre prospective longitudinal observational study (PRELUdiHO) collected between November 2017 and September 2018.

SETTING/PARTICIPANTS

Adult patients (n = 992) enrolled in 13 Italian residential hospices.

METHODS

Two generalized estimating equations logistic models were built, both with number of hospice beds and length of stay as independent variables as well as, in one case, patient-to-healthcare worker ratios, and, in the other, health professionals' qualification levels. Dependent variables were six not clinically significant (score<4) symptoms: pain, nausea, shortness of breath, feeling sad, feeling nervous, and 'how you feel overall', according to the Edmonton Symptom Assessment System revised (ESAS-r) scale.

RESULTS

The generalized estimating equations indicators on staff revealed the following 'optimal' model: Patient-to-Physician ratio (5.5:1-6.5:1); Patient-to-Nurse ratio (1.5:1-2.7:1); Patient-to-Nurse-Assistant ratio (4.1:1-6.3:1); with the most balanced staff composition including 19% physicians, 23% nurse assistants, and 58% registered nurses; hospice beds (12-25); length of stay (median = 12 days). This model predicted an up to four times greater likelihood of controlling all six ESAS-r symptoms over time. The generalized estimating equations model on the educational level of physicians and registered nurses showed that it was significantly associated with optimal patients' symptom control during the entire hospice stay.

CONCLUSIONS

This study showed the exact skill-mix composition and proportions of palliative care team able to ensure optimal control of patients' symptoms. The added value of physicians and nurses with a qualification in palliative care in terms of better patient outcomes reaffirmed the importance of education in guaranteeing quality care. Hospices with 12-25 beds, and recruitment methods guaranteeing at least 12-day stay ensured the most propitious organizational environment for optimal management of clinically significant symptoms. The transferability of these results mainly depends on whether the skills of health professionals in our `ideal' model are present in other contexts. Our results provide policymakers and hospice managers with specific, evidence-based information to support decision-making processes regarding hospice staffing and organization. Further prospective studies are needed to confirm the positive impact of this 'optimal' organizational framework on patient outcomes.

Should end-of-life patients be enrolled as participants in clinical research? A best-fit framework synthesis

AIM

To identify and appraise evidence about ethical concerns regarding conducting medical research with end-of-life patients.

DESIGN

A best-fit framework synthesis of the literature regarding ethical issues in research involving adult patients at the end of life was conducted.

DATA SOURCES

Five databases were searched (Cumulative Index to Nursing and Allied Health Literature, Web of Science, Embase, MEDLINE, and PsychINFO) between January 2000-August 2019.

REVIEW METHODS

Data were synthesized and categorized according to the moral positions described by Foster.

RESULTS

In all, 18 papers that met the inclusion criteria were included in this review. These papers provided rich knowledge not only about various ethical objections to researching the end of life but also about the social, moral, and clinical requirements to perform rigorous studies on clinical interventions in this field.

CONCLUSIONS

Research on people at end of life is not an unsolvable ethical dilemma between providing the best possible care and enhancing new therapies. It is important to find a balance between the moral duties of providing care and achieving research outcomes that are rigorous and meaningful for service users.

IMPACT

Research ethics committees can be challenged by the evaluation of human research. This review provides up-to-date evidence on key challenges and ethical considerations about researching with end-of-life patients.

SUMMARY STATEMENT

This study is a review of relevant evidence and key ethical challenges and issues around palliative and end-of-life research. Our findings provided important recommendations for clinicians, research, and ethics committee members when evaluating clinical research with people at their end of life.

Prevalence, incidence and associated factors of pressure injuries in hospices: A multicentre prospective longitudinal study

BACKGROUND

Patients in palliative care are the population cohort that most frequently develop pressure injuries, severely impacting their quality of life. Data from prospective studies on the prevalence and incidence of pressure injuries in hospices are lacking.

AIM

To describe the point prevalence and cumulative incidence of pressure injuries in patients admitted to residential hospices, and to analyze their predictive factors over time.

DESIGN

Multicentre prospective longitudinal observational study.

SETTING/PARTICIPANTS

Adult patients (n = 992) enrolled in 13 Italian residential hospices, with a minimum sample of 280 for each macro-region (North, center, South/Islands).

METHODS

Assessments including the Karnofsky Performance Status, Braden, Edmonton Symptom Assessment System Revised scales and pressure injury staging according to National Pressure Ulcer Advisory Panel were conducted at least every four days, from admission to patients' death/discharge.

RESULTS

The 7,967 observations recorded provided prevalence and incidence rates of 34.1% and 26.5%, respectively. The logistic regression model showed non-cancer disease (OR = 2.39, 95%CI = 1.65-3.47), age >80 (OR = 2.01, 95%CI = 1.49-2.71), Braden score 'at risk' (OR = 1.92, 95%CI = 1.17-3.14), urinary catheter (OR = 1.96, 95%CI = 1.40-2.75), drowsiness (OR = 1.41, 95%CI = 1.02-1.95) and artificial nutrition (OR = 1.47, 95%CI = 1.01-2.14) as the variables associated with pressure injury at admission. The generalized estimating equations models, built on the timeframes for observation groups, revealed male gender (OR = 1.68, 95%CI = 1.01-2.79) and Braden score 'at risk' (OR = 4.45, 95%CI = 1.74-11.34) as predictive factors of a new pressure injury developed up to three weeks before a patient's death, while in the last ten days of life these predictors were replaced by diagnosis of cancer (OR = 1.80, 95%CI = 1.11-2.91), worsening pain (OR = 1.65, 95%CI = 1.10-2.49), drowsiness (OR = 1.79, 95%CI = 1.25-2.57) and dyspnea (OR = 1.48, 95%CI = 1.01-2.18).

CONCLUSIONS

The high incidence and prevalence of pressure injuries confirm the importance of palliative care nurses continuously focusing on prevention and management strategies. In the last three weeks of a patient's life, the predictive power of the Braden scale for a new pressure injury is not confirmed, throwing doubt on the effectiveness of aimed interventions at modifying risk factors. Along the different disease trajectories, pressure injuries developed during the instability/worsening phases of illness, occurring before hospice admission for non-cancer patients and in the end-of-life phase for cancer patients. Despite continuous provision of appropriate interventions, most of the new pressure injuries were detected during the last ten days of a patient's' life and assessed as 'unavoidable'. These results are crucial to guiding palliative care nursing plans during the different phases of illness, and to predicting care needs, possible management strategies ('wound management' vs. 'wound palliation'), and resource utilization.

Systematic reviews of empirical literature on bioethical topics: Results from a meta-review

BACKGROUND

In bioethics, especially nursing ethics, systematic reviews are increasingly popular. The overall aim of a systematic review is to provide an overview of the published discussions on a specific topic. While a meta-review on systematic reviews on normative bioethical literature has already been performed, there is no equivalent for systematic reviews of empirical literature on ethical topics.

OBJECTIVE

This meta-review aims to present the general trends and characteristics of systematic reviews of empirical bioethical literature and to evaluate their reporting quality.

RESEARCH DESIGN

Literature search was performed on PubMed and Google Scholar. Qualitative content analysis and quantitative approaches were used to evaluate the systematic reviews. Characteristics of systematic reviews were extracted and quantitatively analyzed. The reporting quality was measured using an adapted PRISMA checklist.

FINDINGS

Seventy-six reviews were selected for analysis. Most reviews came from the field of nursing (next to bioethics and medicine). Selected systematic reviews investigated issues related to clinical ethics (50%), followed by research ethics (36%) and public health ethics or organizational ethics (14%). In all, 72% of the systematic reviews included authors' ethical reflections on the findings and 59% provided ethical recommendations. Despite the heterogeneous reporting of the reviews, reviews using PRISMA tended to score better regarding reporting quality.

DISCUSSION

The heterogeneity currently observed is due both to the interdisciplinary nature of nursing ethics and bioethics, and to the emerging nature of systematic review methods in these fields. These results confirm the findings of our previous review of systematic reviews on normative literature, thereby highlighting a recurring methodological gap in systematic reviews of bioethical literature. This also indicates the need to develop more robust methodological standards.

CONCLUSION

Through its extensive overview of the characteristics of systematic reviews of empirical literature on ethical topics, this meta-review is expected to inform further discussions on minimal standards and reporting guidelines.

Relational ethics in palliative care research: including a person-centred approach

The traditional approach to research ethics is to ensure that all ethical issues are adhered to through the scrutiny of research proposals by research ethics committees, themselves sitting within national research governance frameworks. The current approach implies that all potential ethical issues can be considered and mitigated prior to the research. This article is a perspective piece whereby we consider how this approach, on its own, is not enough to ensure ethical practice. We draw attention to the limitations of current ethical procedures in the inherent detachment between the researcher and research participants. We argue that applying a person-centred approach to research ethics allows for contextual and situational factors and places the relationship between research participants and researcher as central.

The Benefits and Burdens of Pediatric Palliative Care and End-of-Life Research: A Systematic Review

Objective: The aim of this study is to report the benefits and burdens of palliative research participation on children, siblings, parents, clinicians, and researchers. Background: Pediatric palliative care requires research to mature the science and improve interventions. A tension exists between the desire to enhance palliative and end-of-life care for children and their families and the need to protect these potentially vulnerable populations from untoward burdens. Methods: Systematic review followed PRISMA guidelines with prepared protocol registered as PROSPERO #CRD42018087304. MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and The Cochrane Library were searched (2000-2017). English-language studies depicting the benefits or burdens of palliative care or end-of-life research participation on either pediatric patients and/or their family members, clinicians, or study teams were eligible for inclusion. Study quality was appraised using the Mixed Methods Appraisal Tool (MMAT). Results: Twenty-four studies met final inclusion criteria. The benefit or burden of palliative care research participation was reported for the child in 6 papers; siblings in 2; parents in 19; clinicians in 3; and researchers in 5 papers. Benefits were more heavily emphasized by patients and family members, whereas burdens were more prominently emphasized by researchers and clinicians. No paper utilized a validated benefit/burden scale. Discussion: The lack of published exploration into the benefits and burdens of those asked to take part in pediatric palliative care research and those conducting the research is striking. There is a need for implementation of a validated benefit/burden instrument or interview measure as part of pediatric palliative and end-of-life research design and reporting.

The 'lived experience' of palliative care patients in one acute hospital setting - a qualitative study

Background

There is limited understanding of the ‘lived experience’ of palliative care patient within the acute care setting. Failing to engage with and understand the views of patients and those close to them, has fundamental consequences for future health delivery. Understanding ‘patient experience’ can enable care providers to ensure services are responsive and adaptive to individual patient need.

Methods

The aim of this study was to explore the ‘lived experience’ of a group of patients with palliative care needs who had recently been in-patients in one acute hospital trust in the north-west of England.

Qualitative research using narrative interviews was undertaken, and data was analysed using thematic analysis. A sample of 20 consecutive patients complying with the inclusion/exclusion criteria were recruited and interviewed.

Results

Patient Sample:

Of the 20 patients recruited, there was a fairly equal gender split; all had a cancer diagnosis and the majority were white British, with an age range of 43–87 years.

Findings from Interviews:

Overall inpatient experience was viewed positively. Individual narratives illustrated compassionate and responsive care, with the patient at the centre. Acts of compassion appeared to be expressed through the ‘little things’ staff could do for patients, i.e., time to talk, time to care, humanity and comfort measures. AHSPCT involvement resulted in perceived improvements in pain control and holistic wellbeing. However, challenges were evident, particularly regarding over-stretched staff and resources, and modes of communication, which seemed to impact on patient experience.

Conclusions

Listening to patients’ experiences of care across the organisation provided a unique opportunity to impact upon delivery of care. Further research should focus on exploring issues such as: why some patients within the same organisation have a positive experience of care, while others may not; how do staff attitudes and behaviours impact on the experience of care; transitions of care from hospital to home, and the role of social networks.

Dying persons' perspectives on, or experiences of, participating in research: An integrative review

BACKGROUND

Conducting research with dying persons can be controversial and challenging due to concerns for the vulnerability of the dying and the potential burden on those who participate with the possibility of little benefit.

AIM

To conduct an integrative review to answer the question 'What are dying persons' perspectives or experiences of participating in research?

DESIGN

A structured integrative review of the empirical literature was undertaken.

DATA SOURCES

Cumulative Index Nursing and Allied Health Complete, PsycINFO, MEDLINE, Informit and Embase databases were searched for the empirical literature published since inception of the databases until February 2017.

RESULTS

From 2369 references, 10 papers were included in the review. Six were qualitative studies, and the remaining four were quantitative. Analysis revealed four themes: value of research, desire to help, expression of self and participation preferences. Dying persons value research participation, regarding their contribution as important, particularly if it provides an opportunity to help others. Participants perceived that the potential benefits of research can and should be measured in ways other than life prolongation or cure. Willingness to participate is influenced by study type or feature and degree of inconvenience.

CONCLUSION

Understanding dying persons' perspectives of research participation will enhance future care of dying persons. It is essential that researchers do not exclude dying persons from clinically relevant research due to their prognosis, fear or burden or perceived vulnerability. The dying should be afforded the opportunity to participate in research with the knowledge it may contribute to science and understanding and improve the care and treatment of others.

The under reporting of recruitment strategies in research with children with life-threatening illnesses: A systematic review

BACKGROUND

Researchers report difficulties in conducting research with children and young people with life-limiting conditions or life-threatening illnesses and their families. Recruitment is challenged by barriers including ethical, logistical and clinical considerations.

AIM

To explore how children and young people (aged 0-25 years) with life-limiting conditions or life-threatening illnesses and their families were identified, invited and consented to research published in the last 5 years.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, PsycINFO, Web of Science, Sciences Citation Index and SCOPUS were searched for original English language research published between 2009 and 2014, recruiting children and young people with life-limiting conditions or life-threatening illness and their families.

RESULTS

A total of 215 studies - 152 qualitative, 54 quantitative and 9 mixed methods - were included. Limited recruitment information but a range of strategies and difficulties were provided. The proportion of eligible participants from those screened could not be calculated in 80% of studies. Recruitment rates could not be calculated in 77%. A total of 31% of studies recruited less than 50% of eligible participants. Reasons given for non-invitation included missing clinical or contact data, or clinician judgements of participant unsuitability. Reasons for non-participation included lack of interest and participants' perceptions of potential burdens.

CONCLUSION

All stages of recruitment were under reported. Transparency in reporting of participant identification, invitation and consent is needed to enable researchers to understand research implications, bias risk and to whom results apply. Research is needed to explore why consenting participants decide to take part or not and their experiences of research recruitment.

Borrowed beauty? Understanding identity in Asian facial cosmetic surgery

This review aims to identify (1) sources of knowledge and (2) important themes of the ethical debate related to surgical alteration of facial features in East Asians. This article integrates narrative and systematic review methods. In March 2014, we searched databases including PubMed, Philosopher's Index, Web of Science, Sociological Abstracts, and Communication Abstracts using key terms "cosmetic surgery," "ethnic*," "ethics," "Asia*," and "Western*." The study included all types of papers written in English that discuss the debate on rhinoplasty and blepharoplasty in East Asians. No limit was put on date of publication. Combining both narrative and systematic review methods, a total of 31 articles were critically appraised on their contribution to ethical reflection founded on the debates regarding the surgical alteration of Asian features. Sources of knowledge were drawn from four main disciplines, including the humanities, medicine or surgery, communications, and economics. Focusing on cosmetic surgery perceived as a westernising practice, the key debate themes included authenticity of identity, interpersonal relationships and socio-economic utility in the context of Asian culture. The study shows how cosmetic surgery of ethnic features plays an important role in understanding female identity in the Asian context. Based on the debate themes authenticity of identity, interpersonal relationships, and socio-economic utility, this article argues that identity should be understood as less individualistic and more as relational and transformational in the Asian context. In addition, this article also proposes to consider cosmetic surgery of Asian features as an interplay of cultural imperialism and cultural nationalism, which can both be a source of social pressure to modify one's appearance.

Participation in a clinical trial for a child with cancer is burdensome for a minority of children

AIM

This study explored how parents who had lost a child to cancer felt about them taking part in a clinical trial.

METHODS

A retrospective questionnaire was sent to parents who had lost a child to cancer. They were asked whether their child took part in a clinical trial during their palliative phase, their motives for their child's participation, how they perceived their child's burden and whether they would, hypothetically speaking, enrol again.

RESULTS

The 24 parents of 16 deceased children who had participated in a clinical trial explained their motives for their child's participation. The most common answers, with multiple responses, were treatment for future patients (n = 16), hope for a cure (n = 9) and prolonging their child's life (n = 6). Eight parents said that participating was not burdensome for their child and four said it was very burdensome, with others answering in between. None of the parents would decline participation if they would be in the same situation again.

CONCLUSION

Performing clinical trials, even in a vulnerable population, such as children with cancer at the end of life, may not always lead to increased burden. None of the parents would in future, given the same circumstances, decline participation in a clinical trial.

How young people describe the impact of living with and beyond a cancer diagnosis: feasibility of using social media as a research method

OBJECTIVE

Young people with cancer exhibit unique needs. During a time of normal physical and psychological change, multiple disease and treatment-related symptoms cause short and long-term physical and psychosocial effects. Little is known about how young people cope with the impact of cancer and its treatment on daily routines and their strategies to manage the challenges of cancer and treatments. We aimed to determine how young people describe these challenges through a social media site.

METHODS

Using the principles of virtual ethnography and watching videos on a social media site we gathered data from young people describing their cancer experience. Qualitative content analysis was employed to analyse and interpret the narrative from longitudinal 'video diaries' by 18 young people equating to 156 films and 27 h and 49 min of recording. Themes were described then organized and clustered into typologies grouping commonalities across themes.

RESULTS

Four typologies emerged reflective of the cancer trajectory: treatment and relenting side effects, rehabilitation and getting on with life, relapse, facing more treatment and coming to terms with dying.

CONCLUSIONS

This study confirms the need for young people to strive towards normality and creating a new normal, even where uncertainty prevailed. Strategies young people used to gain mastery over their illness and the types of stories they choose to tell provide the focus of the main narrative. Social Media sites can be examined as a source of data, to supplement or instead of more traditional routes of data collection known to be practically challenging with this population. Copyright © 2016 John Wiley & Sons, Ltd.

An examination of the research priorities for a hospice service in New Zealand: A Delphi study

Objectives:

Palliative care research is relatively diverse and prioritizing research in this field is dependent on multiple factors such as complex ethical decisions in designing and conducting the research; access to participants who may be deemed “vulnerable” and an increasingly medically focused approach to care. The aim of this study was to inform organizational decision-making and policy development regarding future research priorities for a hospice service in New Zealand.

Methods:

A modified three-round Delphi technique was employed. Participants were drawn from one dedicated specialist palliative care service that delivers care in the community, day-care, hospice inpatient, aged residential care, and acute hospital palliative care service. A purposive sample included palliative care staff (n = 10, 18, 9, for rounds 1–3, respectively) volunteers (n = 10, 12, 11); and patients and family carers (n = 6, 8, for rounds 1 and 2). Patients and family carers were not involved in the third round.

Results:

At final ranking of six research themes encompassing 23 research topics were identified by staff and volunteers. These were: symptom management; aged care; education; community; patient and family; and bereavement support and young people. Patients and family carers agreed on four themes, made up of 10 research topics. These were: decision-making, bereavement and loss, symptom management; and recognition of need and response of service.

Significance of results:

The study generated a rich set of research themes and specific research topics. The perspectives of staff and volunteers are significantly different from those of patients and family members, in spite of the recognition by all concerned that palliative care services work within a philosophy of patient-centered care. Open discussion of ideas has the potential to engage both staff and patients and carers in quality improvement initiatives, and to reinforce the value of research for patient care.

Chinese students studying at Australian universities with specific reference to nursing students: a narrative literature review

OBJECTIVE

To report the current knowledge on the Chinese nursing students' learning at Australian universities. The intent is to provide educators and researchers with a background to the contexts, the methodologies, the emphases of various relevant studies, and to provide recommendations for future research.

BACKGROUND

Attracting international students has become an important part of Australian universities' business and contributes to their cultural diversity. Teaching international students has received considerable attention in the educational research literature. Experiences of international students can vary greatly depending on their country of origin. This paper critically reviews current literature relating to issues for Chinese students and in particular, Chinese nursing students, the biggest single group of international nursing students at Australian universities

DESIGN

Narrative literature review.

METHOD

A comprehensive search of seven electronic databases for literature between 2003 and 2014 helped to identify qualitative and quantitative studies that addressed issues of Asian international students with English as a second language (ESL) (included nursing students) studying in Australia, New Zealand, the UK, the United States and China. Pertinent websites were also searched. The reference lists and bibliographies of retrieved articles were hand- searched to identify other relevant studies.

RESULTS

Fifteen studies met the inclusion criteria for the review. The majority of existing literature claimed that there is a range of challenges confronting international students including Chinese nursing students, in assimilation into their host country. These include issues with English language proficiency, cultural barriers, social problems, different learning styles, academic demands, perceived racism, homesickness, lack of assertiveness and financial problems.

CONCLUSION

There is limited research about the Chinese students' study in Australia. In particular, the learning experience of Chinese nursing students has not been fully explored nor understood. This paper highlights the need for further research into the lived learning experience of Chinese nursing students studying at Australian universities.

Inviting parents to take part in paediatric palliative care research: a mixed-methods examination of selection bias

BACKGROUND

Recruitment to paediatric palliative care research is challenging, with high rates of non-invitation of eligible families by clinicians. The impact on sample characteristics is unknown.

AIM

To investigate, using mixed methods, non-invitation of eligible families and ensuing selection bias in an interview study about parents' experiences of advance care planning (ACP).

DESIGN

We examined differences between eligible families invited and not invited to participate by clinicians using (1) field notes of discussions with clinicians during the invitation phase and (2) anonymised information from the service's clinical database.

SETTING

Families were eligible for the ACP study if their child was receiving care from a UK-based tertiary palliative care service (Group A; N = 519) or had died 6-10 months previously having received care from the service (Group B; N = 73).

RESULTS

Rates of non-invitation to the ACP study were high. A total of 28 (5.4%) Group A families and 21 (28.8%) Group B families (p < 0.0005) were invited. Family-clinician relationship appeared to be a key factor associated qualitatively with invitation in both groups. In Group A, out-of-hours contact with family was statistically associated with invitation (adjusted odds ratio 5.46 (95% confidence interval 2.13-14.00); p < 0.0005). Qualitative findings also indicated that clinicians' perceptions of families' wellbeing, circumstances, characteristics, engagement with clinicians and anticipated reaction to invitation influenced invitation.

CONCLUSION

We found evidence of selective invitation practices that could bias research findings. Non-invitation and selection bias should be considered, assessed and reported in palliative care studies.

Data analysis methods for assessing palliative care interventions in one-group pre-post studies

Objectives:

Studies of palliative care are often performed using single-arm pre–post study designs that lack causal inference. Thus, in this study, we propose a novel data analysis approach that incorporates risk factors from single-arm studies instead of using paired t-tests to assess intervention effects.

Methods:

Physical, psychological and social evaluations of eligible cancer inpatients were conducted by a hospital-based palliative care team. Quality of life was assessed at baseline and after 7 days of symptomatic treatment using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL. Among 35 patients, 9 were discharged within 1 week and 26 were included in analyses. Structural equation models with observed measurements were applied to estimate direct and indirect intervention effects and simultaneously consider risk factors.

Results:

Parameters were estimated using full models that included associations among covariates and reduced models that excluded covariates with small effects. The total effect was calculated as the sum of intervention and covariate effects and was equal to the mean of the difference (0.513) between pre- and post-intervention quality of life (reduced model intervention effect, 14.749; 95% confidence intervals, −4.407 and 33.905; p = 0.131; covariate effect, −14.236; 95% confidence interval, −33.708 and 5.236; p = 0.152).

Conclusion:

Using the present analytical method for single-arm pre–post study designs, factors that modulate effects of interventions were modelled, and intervention and covariate effects were distinguished based on structural equation model.

Conducting research interviews with bereaved family carers: when do we ask?

BACKGROUND

Interviews with bereaved family carers to examine the end-of-life experience of the deceased are important tools for palliative care researchers, but the ethics of approaching the bereaved when they are grieving and vulnerable is often debated.

OBJECTIVE

The aim of this study was to explore the insights of bereaved family carers about the most appropriate time to be involved in a research interview about the end of life and death of their family member.

METHODS

This qualitative study used a social constructionist framework. Twenty-two bereaved family carers of people with motor neurone disease (MND) and cancer were interviewed in Western Australia.

RESULTS

Most family carers (86%) feel comfortable being interviewed about the death of their family member within the first 5 months of bereavement, with 43% reporting they could be interviewed within weeks after death. Family carers reported that recall would be better earlier in bereavement and felt it may be helpful to them to talk about their experiences earlier. They said bereaved people should be allowed to decide for themselves when to be involved in an interview.

CONCLUSIONS

These findings indicate that interviews with the bereaved may be most fruitful for researchers and beneficial to family carers when they are allowed to make the choice about timing for themselves, beginning weeks after the death of their family member.

Uptake of clinical trials in a palliative care setting: a retrospective cohort study

AIM

There has been growth in the number of clinical trials conducted in the palliative care setting. However, issues exist regarding patient acceptance and vulnerability as well as the appropriateness of conducting trials in the dying patient. This study aimed to investigate the uptake of palliative care clinical trials at the Royal Melbourne Hospital, evaluate patient demographics for those enrolled onto study and assess the proportion of patients who died within 28 days of enrolling on a palliative care clinical trial.

METHOD

A retrospective cohort study of all patients prescreened and enrolled onto palliative care clinical trials by the Palliative Care Clinical Trials Team (PCCTT) at the Royal Melbourne Hospital over a 27-month period was undertaken.

RESULTS

Of 515 patients referred to the PCCTT for consideration of trial enrollment, 64 (12.4%) were subsequently enrolled onto one of six clinical trials open during the study period. About 62.5% were non-cancer patients; 81.3% of all patients completed the trial intervention and 65.6% completed trial follow-up; 28.1% of patients enrolled died within 28 days of trial commencement.

CONCLUSION

More than 500 patients were referred for assessment of clinical trial participation perhaps reflecting clinician acceptance of palliative care clinical trials. A number of enrolled patients were involved in trials during their terminal phase, indicating a willingness of participants to be involved, despite poor prognosis.

Ethical challenges and solutions regarding delirium studies in palliative care

CONTEXT

Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges.

OBJECTIVES

Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients.

METHODS

Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines.

RESULTS

Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models.

CONCLUSION

Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC.

Is the patient satisfaction questionnaire an acceptable tool for use in a hospice inpatient setting? A pilot study

Background

The Patient Satisfaction Questionnaire (PSQ) is an assessment tool used to evaluate patients’ perspectives of their doctor’s communication and interpersonal skills. The present pilot study investigated whether the PSQ could be administered successfully in a hospice inpatient setting and if it is an acceptable tool for completion by patients and relatives in this context.

Methods

The study was conducted in two phases. A first phase was undertaken to establish the process of PSQ administration in a hospice inpatient ward. A second phase of questionnaire administration followed by semi-structured interviews explored inpatient experiences of the questionnaire process.

Results

Overall, 30 inpatients and one relative were invited to complete the PSQ across both phases of data collection, representing 53% of all inpatients at the time of data collection. The remaining 47% were deemed unsuitable to ask due to a diagnosis of dying (24%), confusion (17%), distress (3%) or lack of availability (2%). The average response rate across both phases of data collection was 87%. Qualitative interview data suggested that the PSQ was considered clear, easy to understand and not burdensome in terms of time or effort for this population.

Conclusions

The PSQ appears an acceptable tool to use in a hospice inpatient setting. Many patients welcomed the opportunity to be involved and give feedback. Using a greater proportion of relatives as an alternative source of feedback could be considered in future studies.

Lessons from the field: challenges in accruing hospice heart failure patients to intervention research

Recent clinical practice guidelines suggest that hospice can be a valuable alternative for patients with advanced heart failure (HF). Unfortunately, there are very few evidence-based nursing interventions to guide symptom management for HF patients in hospice and their caregivers. Nevertheless, conducting clinical research in hospice populations remains fraught with methodological and ethical challenges. Our research team was not naive to the fact that hospice research is difficult. We believed that we had prepared well for a number of contingencies before the beginning of our clinical trial testing the feasibility of delivering a psychosocial intervention to caregivers of patients with HF. Despite the team expertise and well-defined recruitment strategies, the recruitment, both accrual and attrition, remained daunting in this population. The purpose of this article was to report the challenges of recruiting hospice patients with HF and caregivers for our randomized clinical trial, those we anticipated and those we did not.

MORECare research methods guidance development: recommendations for ethical issues in palliative and end-of-life care research

BACKGROUND

There is little guidance on the particular ethical concerns that research raises with a palliative care population.

AIM

To present the process and outcomes of a workshop and consensus exercise on agreed best practice to accommodate ethical issues in research on palliative care.

DESIGN

Consultation workshop using the MORECare Transparent Expert Consultation approach. Prior to workshops, participants were sent overviews of ethical issues in palliative care. Following the workshop, nominal group techniques were used to produce candidate recommendations. These were rated online by participating experts. Descriptive statistics were used to analyse agreement and consensus. Narrative comments were collated.

SETTING/PARTICIPANTS

Experts in ethical issues and palliative care research were invited to the Cicely Saunders Institute in London. They included senior researchers, service providers, commissioners, researchers, members of ethics committees and policy makers.

RESULTS

The workshop comprised 28 participants. A total of 16 recommendations were developed. There was high agreement on the issue of research participation and high to moderate agreement on applications to research ethics committees. The recommendations on obtaining and maintaining consent from patients and families were the most contentious. Nine recommendations were refined on the basis of the comments from the online consultation.

CONCLUSIONS

The culture surrounding palliative care research needs to change by fostering collaborative approaches between all those involved in the research process. Changes to the legal framework governing the research process are required to enhance the ethical conduct of research in palliative care. The recommendations are relevant to all areas of research involving vulnerable adults.

Experiences in recruiting volunteers through community based initiatives in phase-1 vaccine trials in India

Success of HIV vaccine trials is dependent on infrastructural preparedness of the site, technical expertise of the trial team and strong Socio-political support of the local community. The processes followed and experiences gained while implementing various community based initiatives for recruitment of healthy volunteers during the three HIV vaccine trials in India are described. Major initiatives in community engagement implemented for the first time in India included establishment and involvement of Community Advisory Board and capacity building and engagement of lay community based volunteers called "peers" using "lay health promotion" model. Community education program designed for trial participants' education, identification and enrollment was a three-tiered approach, moving from large community awareness meetings (first step) to facility-based small group meeting to provide trial specific information (second step); ending with one-to-one vaccine center based meeting with the volunteers to clear doubts, myths, and misconceptions about HIV/AIDS, the experimental vaccine and HIV vaccine trials as well as to explain trial specific procedures (third step). It is important to focus on gender issues, locally relevant socio-cultural factors, informed consent, and post-trial care related matters during the conduct of sensitive clinical trials in socio-culturally diverse and resource limited setting like India.

Overcoming barriers to recruitment in care of the dying research in hospitals

CONTEXT

Approximately 40% of the U.S. and 60% of the U.K. population die in hospital. Many reports have highlighted variability in the care received by these patients and national initiatives have proposed strategies to improve this care. No studies have demonstrated whether any improvements in end-of-life care have been achieved, as research in this area is challenging.

OBJECTIVES

We designed a study to assess the feasibility of a novel method of identifying patients likely to die during an acute hospital admission and a model of prior consent from patients and/or assent from their relatives.

METHODS

A study for collecting data on patients' symptoms before and after the introduction of an end-of-life tool (comprising medical and nursing checklists, prescribing guidance, and a symptom observation chart) within five wards in a major U.K. teaching hospital was conducted. We asked the screening question to a senior member of staff, "Is this patient so unwell that you feel they could die on this admission?" to identify appropriate patients, and recruited using the consent procedure. Patients were enrolled in the study if they became more unwell and data were then collected until they died.

RESULTS

In total, 6642 patients were screened. The ward staff answered "yes" to the screening question for 327 of 6642 (4.9%) patients. Patient's prior consent or relative's assent to enroll in the study was obtained for 117 of 327 (35.8%) patients, of whom 70 of 117 (59.8%) enrolled for the study and died within the study period. The staff found that the methods used were appropriate.

CONCLUSION

We have shown that identifying and involving dying patients in research is possible and acceptable to patients and carers.

The patient's use of metaphor within a palliative care setting: theory, function and efficacy. A narrative literature review

BACKGROUND

The modes of communication which patients use are seen as important within the sphere of palliative care and have been the focus of much research.

AIM

This literature review aims to identify and analyse one particular mode of patient expression, namely that of the figure of speech (trope) 'metaphor', and ask questions regarding metaphor's therapeutic usefulness when engaging with the life-limited patient.

DATA SOURCES

The investigation revolves around a literature review of academic papers which focus on the metaphorical ways in which patients speak of their condition.

RESULTS

This paper provides the theoretical foundations for the patient's metaphoric utterances. It also delineates the variety and diversity of metaphors used by patients and categorises them into broad groupings which encompass metaphors of war, journeying, personhood, the natural world and existential concepts.

CONCLUSIONS

The papers reviewed suggest that metaphoric communication allows sensitive subjects to be dealt with and provides benefits for patients. The results suggest that engaging with patients at the metaphoric level enables them to create new ways of viewing their situation and opens up the possibilities of new coping strategies. Finally, some developmental trajectories emanating from the reviewed papers are suggested, which will allow the efficacy of metaphor to be explored further within a palliative care setting.

A narrative literature review of older people's cancer pain experience

AIMS AND OBJECTIVES

To synthesise current evidence about the experience of older people with cancer pain and consider how exploration of this may inform clinical practice and research.

BACKGROUND

Cancer is more prevalent in older age. Evidence suggests that older people's pain is generally under-recognised and under treated. Pain is a significant concern for many people living and dying with cancer and may be of particular concern for older people who may have complex biopsychosocial needs. There is mounting evidence that older people and their families experience high level of unmet need generally and suboptimal pain in particular.

DESIGN

Narrative literature review.

METHOD

A comprehensive search of five electronic databases was undertaken between the years 1996-2010 inclusive. Inclusion criteria were primary research papers relating older peoples' experiences of cancer pain, incorporating the verbal report or narrative account of experience of cancer.

RESULTS

Seventeen papers met the criteria for inclusion in the review. Three major themes emerged from the literature: (1) emotional experience identified by older people with cancer pain, (2) effects of pain on life and living, and (3) how communication affects the experience or expression of cancer pain including subthemes of validating, trust and cultural effects on the communication of pain.

CONCLUSION

There is limited research about older people's cancer pain from the perspective of the person experiencing the pain. This review highlights the need for further research into living and dying with cancer pain which incorporates the unique and individual experience of older people.

RELEVANCE TO CLINICAL PRACTICE

Understanding the complexity and nature of older people's cancer pain experience should inform appropriate effective care that improves quality of life and promotes independence and dignity. Culturally sensitive training in communication may enhance understanding of the needs of older people with cancer pain.

Participant recruitment in sensitive surveys: a comparative trial of 'opt in' versus 'opt out' approaches

Background

Although in health services survey research we strive for a high response rate, this must be balanced against the need to recruit participants ethically and considerately, particularly in surveys with a sensitive nature. In survey research there are no established recommendations to guide recruitment approach and an ‘opt-in’ system that requires potential participants to request a copy of the questionnaire by returning a reply slip is frequently adopted. However, in observational research the risk to participants is lower than in clinical research and so some surveys have used an ‘opt-out’ system. The effect of this approach on response and distress is unknown. We sought to investigate this in a survey of end of life care completed by bereaved relatives.

Methods

Out of a sample of 1422 bereaved relatives we assigned potential participants to one of two study groups: an ‘opt in’ group (n=711) where a letter of invitation was issued with a reply slip to request a copy of the questionnaire; or an ‘opt out’ group (n=711) where the survey questionnaire was provided alongside the invitation letter. We assessed response and distress between groups.

Results

From a sample of 1422, 473 participants returned questionnaires. Response was higher in the ‘opt out’ group than in the ‘opt in’ group (40% compared to 26.4%: χ² =29.79, p-value<.01), there were no differences in distress or complaints about the survey between groups, and assignment to the ‘opt out’ group was an independent predictor of response (OR=1.84, 95% CI: 1.45-2.34). Moreover, the ‘opt in’ group were more likely to decline to participate (χ²=28.60, p-value<.01) and there was a difference in the pattern of questionnaire responses between study groups.

Conclusion

Given that the ‘opt out’ method of recruitment is associated with a higher response than the ‘opt in’ method, seems to have no impact on complaints or distress about the survey, and there are differences in the patterns of responses between groups, the ‘opt out’ method could be recommended as the most efficient way to recruit into surveys, even in those with a sensitive nature.

Patient, caregiver, health professional and researcher views and experiences of participating in research at the end of life: a critical interpretive synthesis of the literature

Background

The development of the evidence-base informing end of life (EoL) care is hampered by the assumption that patients at the EoL are too vulnerable to participate in research. This study aims to systematically and critically review the evidence regarding the experiences and views of patients, caregivers, professionals and researchers about participation in EoL care research, and to identify best practices in research participation.

Methods

We searched seven electronic databases, and hand searched three journals and the bibliographies of relevant papers. Inclusion criteria were original research papers on involvement in EoL care research or its impact on participants. Critical interpretive synthesis was used to integrate the whole body of empirical evidence on this topic and generate theoretical categories from the evidence.

Results

Of a total of 239 identified studies, 20 studies met the inclusion criteria, from: the US (11), the UK (6) and Australia (3). Most focused on patients with cancer (12) and were conducted in hospices (9) or hospitals (7). Studies enquired about issues related to: EoL care research in general (5), specific research methods (13), and trial research (2). The studies evaluating willingness to participate in EoL care research showed positive outcomes across the different parties involved in research. Factors influencing willingness were mainly physical and cognitive impairment. Participating in research was a positive experience for most patients and carers but a minority experienced distress. This was related to: characteristics of the participants; the type of research; or the way it was conducted. Participatory study designs were found particularly suitable for enabling the inclusion of a wide range of participants.

Conclusion

The evidence explored within this study demonstrates that the ethical concerns regarding patient participation in EoL care research are often unjustified. However, research studies in EoL care require careful design and execution that incorporates sensitivity to participants’ needs and concerns to enable their participation. An innovative conceptual model for research participation relevant for potentially vulnerable people was developed.

Reconciling informed consent and 'do no harm': ethical challenges in palliative-care research and practice in chronic obstructive pulmonary disease

The challenges associated with patient-based research in palliative care are well documented. This paper focuses on the ethical challenges and discusses them in the context of a pilot study to explore the palliative-care needs of patients with moderate and severe chronic obstructive pulmonary disease. The main ethical challenge encountered related to problems surrounding the use of terminology, specifically the terms 'palliative care' and 'chronic obstructive pulmonary disease'. The approving ethics committee specified that these terms be removed from all patient materials in order to protect patients from undue distress. The impact of this ethical advice on patients' ability to give fully informed consent is discussed. This paper highlights a requirement for appropriately resourced and well-managed studies in palliative care, and identifies a need for the development of appropriate strategies in order to ensure the informed participation of patients with non-cancer diagnoses in palliative-care research.