'That's part of everybody's job': the perspectives of health care staff in England and New Zealand on the meaning and remit of palliative care

Identification of core indicators for the integration of a palliative care approach in hospitals: An international Delphi study

BACKGROUND

Healthcare providers working in hospitals have significant exposure to patients with palliative care needs. For many patients, these needs often reflect non-specialist rather than specialist palliative care needs. Embedding a palliative care approach in acute hospital-based care however is challenging.

AIM

To identify core indicators for the integration of a palliative care approach in hospitals.

DESIGN

A Delphi technique used three sequential online survey rounds. Preliminary indicators were identified in a concept analysis of a palliative care approach, and a systematic review of hospital-based healthcare providers' views of a palliative care approach.

PARTICIPANTS

An international expert panel of three key stakeholder groups (clinicians, researchers, patients/family members) participated in each Delphi round.

RESULTS

The Delphi participants were recruited from 12 countries; 97 individuals responded to round 1, 78 to round 2 and 72 to round 3 (74% overall response rate). Consensus was achieved (defined a priori as >70%) on 32 core indicators of a hospital-based palliative care approach, with five structural indicators (relating to infrastructure and governance), 21 organisational indicators (relating to clinical care processes) and six staff indicators (relating to training and support for healthcare providers).

CONCLUSIONS

This study offers multi-level guidance for clinical practice, policy and research related to integration of a palliative care approach in hospitals, based on evidence and international consensus from major stakeholder groups. These core indicators provide a means to assess, review and communicate the core elements of a palliative care approach in hospitals.

Crossing Antarctica: Hospital nurses' experience of knowledge when providing palliative and end of life care

BACKGROUND

Hospitals can be challenging environments for nurses when providing palliative and end-of-life care. Understanding hospital nurses' experiences of their application of palliative and end-of-life knowledge could help direct future education to support such challenging care.

AIM

To understand how hospital nurses use knowledge in palliative and end-of-life care situations.

METHOD

Interpretive phenomenology was used to understand 10 hospital nurses' experiences and ability to apply palliative and end-of-life knowledge.

FINDINGS

The hospital nurses' experiences of knowledge in palliative and end-of-life care was like Crossing Antarctica: unpredictable due to the changing demands and life course leading to uncertainty with knowledge and feeling helpless. Two themes emerged; Knowledge and uncertainty describes feeling unprepared, lacking in knowledge; knowledge and empowerment describes the nurses experiences of applying their knowledge in clinical environments.

CONCLUSION

The nurses' sense of uncertainly could be attributed to their palliative and end-of-life knowledge being systematic, making it difficult for them to manage uncertain situations. Some nurses were empowered to apply knowledge, others were disempowered, suggesting the ability to apply their palliative and end-of-life knowledge is not determined by knowledge alone but also by the position they held.

End-of-Life Care Education as Blended Learning Approach for General Practitioners: a Scoping Review

General practitioners (GPs) are critical in providing primary palliative care in the community. Apprehensions about managing a dying person at home, difficulties in goals of care discussion, limited resources and lack of palliative care education often hinder end-of-life care provision in the community. This review focused on the end-of-life care training programs accessed by GPs and sought to understand if the training programs' content and mode of delivery aligned with their preferred needs. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to identify articles published in English between 01 January 1990 and 30 September 2022. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. The reviewers screened the titles, abstracts, and full text to identify eligible studies and extracted textual data to analyse and generate themes. Out of 5532 citations initially accessed, 17 studies were included in the review. Six themes were generated: knowledge translation, skill development, a change in attitude, self-efficacy, satisfaction, and patient outcomes. The GPs' end-of-life care knowledge, skills, attitude, self-efficacy, and patient outcomes were better when their training had a combination of small-group interactive workshops, trigger case-based reflective learning, mentor-facilitated experiential learning, web-based modules, and peer learning. The synthesis of review findings supports blended learning as a training approach for general the practitioners' end-of-life care education as it facilitates learning and patient outcomes.

Using Social Constructivist Learning Theory to Unpack General Practitioners' Learning Preferences of End-of-Life Care: A Systematically Constructed Narrative Review

General practitioners play a vital role in providing community-based palliative care to patients reaching end of life. In order for GPs to upgrade their skills at end-of-life care delivery, it is imperative that training programs be aligned to their learning needs and preferences. A narrative review was conducted using the electronic databases PubMed, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane from 01/01/1990 to 31/05/2021. 23 articles (of 10037 searched) were included for the review. Following themes were generated: Value attributed to end-of-life care learning, experience and reflection as a departure point for learning, learning as embedded in the clinical context; autonomy to decide upon their learning needs and learning preferences, learning as a transformative process; and learning as embedded in social interaction and interpretation. Training programs that are aligned to the preferences of GPs will encourage a larger clientele of GPs to access them.

Description of patient reported experience measures (PREMs) for hospitalised patients with palliative care needs and their families, and how these map to noted areas of importance for quality care: A systematic review

BACKGROUND

The global need for focused improvements in palliative care within the acute hospital setting is well noted. A large volume of evidence exists detailing what hospitalised patients with palliative care needs and their families note as important for high quality care. Patient Reported Experience Measures (PREMs) are one mechanism that hospitals could use to inform improvement work. To date there has not been a review of PREMs available for hospitalised patients with palliative care needs and/or their family, nor how they align with noted priorities for high quality care.

AIM

To identify and describe PREMs designed for hospitalised patients with palliative care needs and their families; and their alignment with patient and family identified domains for high quality care.

DESIGN

A systematic review.

DATA SOURCES

A systematic search of CINAHL, Medline and PsycInfo was conducted up to September 23, 2022 and supplemented by handsearching article reference lists and internet searches. PREMs written in English and designed for patients with palliative care needs in acute hospitals were eligible for inclusion. Included PREMs were described by: summarising key characteristics; and mapping their items to domains noted to be important to hospitalised patients with palliative care needs and their families informed by outcomes from a published study completed in 2021. Evidence for psychometric properties were reviewed.

RESULTS

Forty-four PREMs with 827 items were included. Items per PREM varied from 2 to 85 (median 25, IQR 13-42). Two-thirds (n = 534, 65%) of the items were designed for families and a third (n = 283, 34%) for hospitalised patients, and very few (n = 10, 1%) for both. Sixty-six percent of items measured person-centred care, 30% expert care and 4% environmental aspects of care. Available PREMs address between 1 and 11 of the 14 domains of importance for quality palliative care. PREMs had a median of 38% (IQR 25.4-56.3) of items >Grade 8 measured by the Flesch-Kincaid readability test, with Grade 8 or lower recommended to ensure health information is as accessible as possible across the population.

CONCLUSIONS

Whilst 44 PREMs are available for hospitalised patients with palliative care needs or their families, a varied number of items are available for some domains of care provision that are important, compared to others. Few are suitable for people with lower levels of literacy or limited cognitive capacity due to illness.

The perspectives of in-hospital healthcare professionals on the timing and collaboration in advance care planning: A survey study

Background

Hospital admissions are common in the last phase of life. However, palliative care and advance care planning (ACP) are provided late or not at all during hospital admission.

Aim

To provide insight into the perceptions of in-hospital healthcare professionals concerning current and ideal practice and roles of in-hospital palliative care and advance care planning.

Methods

An electronic cross-sectional survey was send 398 in-hospital healthcare professionals in five hospitals in the Netherlands. The survey contained 48 items on perceptions of palliative care and ACP.

Results

We included non-specialists who completed the questions of interest, resulting in analysis of 96 questionnaires. Most respondents were nurses (74%). We found that current practice for initiating palliative care and ACP was different to what is considered ideal practice. Ideally, ACP should be initiated for almost every patient for whom no treatment options are available (96.2%), and in case of progression and severe symptoms (94.2%). The largest differences between current and ideal practice were found for patients with functional decline (Current 15.2% versus Ideal 78.5%), and patients with an estimated life expectancy <1 year (Current 32.6% versus ideal 86.1%). Respondents noted that providing palliative care requires collaboration, however, especially nurses noted barriers like a lack of inter-professional consensus.

Conclusions

The differences between current and ideal practice demonstrate that healthcare professionals are willing to improve palliative care. To do this, nurses need to increase their voice, a shared vision of palliative care and recognition of the added value of working together is needed.

Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital

BACKGROUND

The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool.

METHODS

A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer "NO" and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed.

RESULTS

Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p < 0.001). In 50.8% of cases, no referrals were made to psychology, social work, or hospital palliative and supportive care teams. The three services with the higher number of patients with palliative care needs were: Palliative Care Unit (100%), Oncology (54.54%), and Emergency Short-stay Unit (54.16%).

CONCLUSION

A high percentage of patients admitted to tertiary care hospitals presented palliative care needs, with multiple unmet physical, emotional, and social needs. Less than 50% are referred to specialized care teams, such as hospital palliative and supportive care teams.

How do hospital nurses experience end-of-life care provision? A creative phenomenological approach

BACKGROUND

Current evidence suggests that hospital nurses' end-of-life care is complex due to the conflicting tasks of treatment-focused care and palliation. This is a topic that needs further exploration.

AIM

To understand hospital nurses' experiences of end-of-life care.

METHOD

Interpretive phenomenology was used to explore 10 hospital nurses' experiences.

FINDINGS

Nurses' individual experience of death informed their attitudes to death. The dominant theme was death-as-calm, accompanied by human connection, and death-as-process. The nurses' actions indicated their end-of-life care included love, defined as a desire to create calm, grounded by the virtue of natural goodness, responsibility and dedication, with a willingness to focus on the individual and their family, making the most of whatever time they have left. To continue providing end-of-life care the nurses successfully protected their authentic self by using a 'professional identity' and employing 'defence of self'. The nurses found the unpredictable nature of hospital end-of-life care difficult but used a collaborative power to manage situations.

CONCLUSION

This study suggests hospital nurses successfully navigate an approach to hospital end-of-life nursing care, represented as a 'harbour', which facilitates transitioning from 'stormy' treatment to calm end-of-life care and death.

Views of general practitioners on end-of-life care learning preferences: a systematic review

Background

General practitioners (GPs) play a pivotal role in providing end-of-life care in the community. Although they value end-of-life care, they have apprehensions about providing care in view of the limitations in knowledge and skills in end-of-life care. This review aimed to explore, synthesise, and analyse the views of general practitioners on end-of-life care learning preferences.

Methods

MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane were searched for literature on the views of general practitioners on end-of-life care learning preferences from 01/01/1990 to 31/05/2021. Methodological quality was reported.

Results

Of the 10,037 articles identified, 23 were included for the review. Five themes developed from the review. The desire to provide palliative care, as well as self-actualisation needs, relevance to practice, a sense of responsibility, and a therapeutic bond, motivates general practitioners to learn end-of-life care. Some of the learning needs expressed were pain and symptom management, communication skills, and addressing caregiver needs. Experiential learning and pragmatist learning styles were preferred learning styles. They perceived the need for an amicable learning environment in which they could freely express their deficiencies. The review also identified barriers to learning, challenges at personal and professional level, feelings of disempowerment, and conflicts in care.

Conclusion

GPs’ preference for learning about end-of-life care was influenced by the value attributed to learning, context and content, as well as preference for learning styles and the availability of resources. Thus, future trainings must be in alignment with the GPs’ learning preferences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01053-9.

Perfil de pacientes con cronicidad avanzada y necesidades paliativas: un cambio que no llega

Objetivo: estudiar los posibles cambios en el perfil de pacientes con cronicidad avanzada entre dos cohortes en el momento de su inclusión en un equipo de soporte de atención paliativa domiciliaria (ESAPD) en el marco de la implementación de estrategias de cronicidad. Método: estudio observacional retrospectivo con enfoque analítico de pacientes no oncológicos derivados a un ESAPD de la Comunidad de Madrid, divididos en dos cohortes (2014 y 2019) definidas por el momento de inclusión en programa. Las variables principales fueron: tiempo de permanencia en programa (TPP), carga sintomática (CS) y situación funcional (SF). Se recogieron variables sociodemográficas y clínicas. Se comparó globalmente y por sexo el efecto de la cohorte (bruto y ajustado) sobre las variables principales mediante LogRank y Cox para el TPP, t-Student para la CS y SF y Modelo Lineal Generalizado para la SF. Resultados: las cohortes 2014 y 2019 constaron, respectivamente, de 98 y 116 pacientes, 63% y 52% de mujeres, 48% y 35% del ámbito rural y 43% y 27% de institucionalizados, con una media de edad y lugar de fallecimiento similares. En el TPP no se evidenciaron diferencias entre ambas cohortes (p=0,098); el análisis de Cox tampoco mostró asociación (HR = 1,01 [0,75; 1,36]). En la CS no se encontraron diferencias clínicamente relevantes. No se observaron diferencias en la SF una vez ajustada por las variables edad, sexo e institucionalización. Conclusión: no se observaron diferencias en el perfil de pacientes con cronicidad avanzada incluidos en el programa del ESAPD entre los años 2014 y 2019 en el marco de la implementación de estrategias de cronicidad. Palabras clave: cuidados paliativos, Atención Primaria, enfermedad crónica, diagnóstico precoz, anciano frágil.

Perfil de pacientes con cronicidad avanzada y necesidades paliativas: un cambio que no llega

Objetivo: estudiar los posibles cambios en el perfil de pacientes con cronicidad avanzada entre dos cohortes en el momento de su inclusión en un equipo de soporte de atención paliativa domiciliaria (ESAPD) en el marco de la implementación de estrategias de cronicidad. Método: estudio observacional retrospectivo con enfoque analítico de pacientes no oncológicos derivados a un ESAPD de la Comunidad de Madrid, divididos en dos cohortes (2014 y 2019) definidas por el momento de inclusión en programa. Las variables principales fueron: tiempo de permanencia en programa (TPP), carga sintomática (CS) y situación funcional (SF). Se recogieron variables sociodemográficas y clínicas. Se comparó globalmente y por sexo el efecto de la cohorte (bruto y ajustado) sobre las variables principales mediante LogRank y Cox para el TPP, t-Student para la CS y SF y Modelo Lineal Generalizado para la SF. Resultados: las cohortes 2014 y 2019 constaron, respectivamente, de 98 y 116 pacientes, 63% y 52% de mujeres, 48% y 35% del ámbito rural y 43% y 27% de institucionalizados, con una media de edad y lugar de fallecimiento similares. En el TPP no se evidenciaron diferencias entre ambas cohortes (p=0,098); el análisis de Cox tampoco mostró asociación (HR = 1,01 [0,75; 1,36]). En la CS no se encontraron diferencias clínicamente relevantes. No se observaron diferencias en la SF una vez ajustada por las variables edad, sexo e institucionalización. Conclusión: no se observaron diferencias en el perfil de pacientes con cronicidad avanzada incluidos en el programa del ESAPD entre los años 2014 y 2019 en el marco de la implementación de estrategias de cronicidad. Palabras clave: cuidados paliativos, Atención Primaria, enfermedad crónica, diagnóstico precoz, anciano frágil.

Clinical nurse specialist role in providing generalist and specialist palliative care: A qualitative study of mesothelioma clinical nurse specialists

Aim

To explore perspectives of Mesothelioma UK clinical nurse specialists (CNSs) on their role in providing palliative care for patients with mesothelioma and their families.

Design

A qualitative descriptive approach using focus group and interview methods.

Methods

Focus groups and semi‐structured interviews were conducted with 16 Mesothelioma UK clinical nurse specialists using the online software Google Meet. Data collection was carried out in Jan‐Feb 2021 and data were analysed using thematic analysis. The consolidated criteria for reporting qualitative research (COREQ) was used as the reporting guideline for this paper.

Results

Four main themes were identified from the data: Mesothelioma UK clinical nurse specialist role in relation to palliative care; joint working with specialist palliative care and community services; patients and family carer's willingness to engage with palliative care services; and the impact of COVID‐19 on palliative care for mesothelioma patients.

Conclusion

This study provides valuable insights into palliative care needs in mesothelioma. Patients with mesothelioma and their families have significant palliative care needs throughout the course of their illness from diagnosis to the end of life. Mesothelioma UK CNS's play a crucial role in supporting patients' and families palliative care needs, and are highly skilled in providing this care.

Impact

By acknowledging the role of Mesothelioma UK CNS's in palliative care provision, and supporting collaborative working between specialist and generalist palliative care providers, there is the capacity to significantly improve palliative care in mesothelioma and improve outcomes for patients and their families.

Evolution of Oncology and Palliative Nursing in Meeting the Changing Landscape of Cancer Care

Nursing is a vital health profession. In almost all clinical and hospital settings, nurses offer primary palliative care. Nurses are recognized for their strong philosophy of care for a wide spectrum of disorders. No matter the sickness, condition, or clinical situation, palliative care is considered essential in nursing practice. Palliative care nursing is the provision of palliative care services to cancer patients and their families, regardless of whether cancer can be cured or not. A large body of evidence shows that early palliative care nursing integration improves the quality of life and survival of cancer patients. Due to the intricacy of cancer, the landscape of cancer care is shifting. Cancer is a life-threatening disease with a high mortality rate. Oncology nurses' skills and experience are vital in providing specialized patient care and fulfilling the needs of patients and their families. The current study examines the shifting environment of palliative care nursing in oncology. However, new palliative care nursing approaches are required to adapt to the evolving cancer scenario.

Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand

A generalist-specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers-Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that "generalists" are willing and able to play a key role in palliative care provision needs to be further challenged.

The Online Representation of Palliative Care by Practice, Policy, and Advocacy Organizations: Definitional Variations and Discursive Tensions

Negative beliefs and a lack of clarity surrounding the meaning of palliative care have been widely reported as obstacles to its uptake. Information available to the public possibly contributes to this. A descriptive and discourse-theoretical analysis was conducted of information spread online by palliative care policy, advocacy, and practice organizations. Discrepancies were found in the way palliative care was defined in relation to curative, end-of-life, terminal, and supportive care. Beyond these definitional variations, meaning was generated through the representation of palliative care as a culture, connected to total care, compassion, and openness. Tensions arose around the concepts of autonomy, a natural death, and an emphasis on the quality of life away from death and dying. Overall, this study showed that the online information of palliative care is a potential source of confusion and might even contribute to its stigmatization. Insights are provided that may help improve clarity toward the public.

Pain self-management interventions for community-based patients with advanced cancer: a research programme including the IMPACCT RCT

Background

Each year in England and Wales, 150,000 people die from cancer, of whom 110,000 will suffer from cancer pain. Research highlights that cancer pain remains common, severe and undertreated, and may lead to hospital admissions.

Objective

To develop and evaluate pain self-management interventions for community-based patients with advanced cancer.

Design

A programme of mixed-methods intervention development work leading to a pragmatic multicentre randomised controlled trial of a multicomponent intervention for pain management compared with usual care, including an assessment of cost-effectiveness.

Participants

Patients, including those with metastatic solid cancer (histological, cytological or radiological evidence) and/or those receiving anti-cancer therapy with palliative intent, and health professionals involved in the delivery of community-based palliative care.

Setting

For the randomised controlled trial, patients were recruited from oncology outpatient clinics and were randomly allocated to intervention or control and followed up at home.

Interventions

The Supported Self-Management intervention comprised an educational component called Tackling Cancer Pain, and an eHealth component for routine pain assessment and monitoring called PainCheck.

Main outcome measures

The primary outcome was pain severity (measured using the Brief Pain Inventory). The secondary outcomes included pain interference (measured using the Brief Pain Inventory), participants’ pain knowledge and experience, and cost-effectiveness. We estimated costs and health-related quality-of-life outcomes using decision modelling and a separate within-trial economic analysis. We calculated incremental cost-effectiveness ratios per quality-adjusted life-year for the trial period.

Results

Work package 1 – We found barriers to and variation in the co-ordination of advanced cancer care by oncology and primary care professionals. We identified that the median time between referral to palliative care services and death for 42,758 patients in the UK was 48 days. We identified key components for self-management and developed and tested our Tackling Cancer Pain resource for acceptability. Work package 2 – Patients with advanced cancer and their health professionals recognised the benefits of an electronic system to monitor pain, but had reservations about how such a system might work in practice. We developed and tested a prototype PainCheck system. Work package 3 – We found that strong opioids were prescribed for 48% of patients in the last year of life at a median of 9 weeks before death. We delivered Medicines Use Reviews to patients, in which many medicines-related problems were identified. Work package 4 – A total of 161 oncology outpatients were randomised in our clinical trial, receiving either supported self-management (n = 80) or usual care (n = 81); their median survival from randomisation was 53 weeks. Primary and sensitivity analyses found no significant treatment differences for the primary outcome or for other secondary outcomes of pain severity or health-related quality of life. The literature-based decision modelling indicated that information and feedback interventions similar to the supported self-management intervention could be cost-effective. This model was not used to extrapolate the outcomes of the trial over a longer time horizon because the statistical analysis of the trial data found no difference between the trial arms in terms of the primary outcome measure (pain severity). The within-trial economic evaluation base-case analysis found that supported self-management reduced costs by £587 and yielded marginally higher quality-adjusted life-years (0.0018) than usual care. However, the difference in quality-adjusted life-years between the two trial arms was negligible and this was not in line with the decision model that had been developed. Our process evaluation found low fidelity of the interventions delivered by clinical professionals.

Limitations

In the randomised controlled trial, the low fidelity of the interventions and the challenge of the study design, which forced the usual-care arm to have earlier access to palliative care services, might explain the lack of observed benefit. Overall, 71% of participants returned outcome data at 6 or 12 weeks and so we used administrative data to estimate costs. Our decision model did not include the negative trial results from our randomised controlled trial and, therefore, may overestimate the likelihood of cost-effectiveness.

Conclusions

Our programme of research has revealed new insights into how patients with advanced cancer manage their pain and the challenges faced by health professionals in identifying those who need more help. Our clinical trial failed to show an added benefit of our interventions to enhance existing community palliative care support, although both the decision model and the economic evaluation of the trial indicated that supported self-management could result in lower health-care costs.

Future work

There is a need for further research to (1) understand and facilitate triggers that prompt earlier integration of palliative care and pain management within oncology services; (2) determine the optimal timing of technologies for self-management; and (3) examine prescriber and patient behaviour to achieve the earlier initiation and use of strong opioid treatment.

Trial registration

Current Controlled Trials ISRCTN18281271.

Funding

This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 15. See the NIHR Journals Library website for further project information.

Living, loving and letting go-navigating the relational within palliative care of older people in long-term care facilities: An action research study

BACKGROUND

Long term care facilities are important environments for the delivery of palliative care, which includes end of life care. Despite this, staff may feel this care focus is separate to their roles. Consequently, this study explores and makes visible how palliative care is understood in long term residential care facilities for older people. It focuses on how relationships with residents and families are experienced by nurses and health care assistants and how this influences the introduction and provision of palliative care to older people in long term care facilities.

OBJECTIVES

To develop an understanding of what palliative care means to staff caring for older people in residential care.

METHODS

A co-operative inquiry action research approach was used. A total of 18 healthcare assistants and 16 registered nurses in two older person long term care facilities participated in co-operative inquiry groups. Co-inquirers reflected on deaths that occurred over a 6-month period and generated narratives on their relationships in the context of palliative care.

RESULTS

Three themes were identified to describe relationships which were immersed in an ethos of person-centred care. These were living, loving and letting go. Living rather than dying was the predominant focus of care. Loving described deep engagement with older people and families while letting go navigated the dying process.

CONCLUSIONS

Staff in nursing homes experience deep attachments to residents when delivering palliative care and end of life care. There is a need to understand these relationships and how they impact on the understanding and integration of palliative care in older person residential care as well as acknowledging and addressing staff's grief processes to enhance resilience.

Exploring expanded interdisciplinary roles in goals of care conversations in a national goals of care initiative: A qualitative approach

BACKGROUND

The United States Veterans Health Administration National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative throughout the Veterans Health Administration health care system in 2017. This policy encourages goals of care conversations, referring to conversations about patient's treatment and end-of-life wishes for life-sustaining treatments, among Veterans with serious illnesses. A key component of the initiative is expanding interdisciplinary provider roles in having goals of care conversations.

AIM

Use organizational role theory to explore medical center experiences with expanding interdisciplinary roles in the implementation of a goals of care initiative.

DESIGN

A qualitative thematic analysis of semi-structured interviews.

SETTING/PARTICIPANTS

Initial participants were recruited using purposive sampling of local medical center champions. Snowball sampling identified additional participants. Participants included thirty-one interdisciplinary providers from 12 geographically diverse initiative pilot and spread medical centers.

RESULTS

Five themes were identified. Expanding provider roles in goals of care conversations (1) involves organizational culture change; (2) is influenced by medical center leadership; (3) is supported by provider role readiness; (4) benefits from cross-disciplinary role agreement; and (5) can "overwhelm" providers.

CONCLUSIONS

Organizational role theory is a helpful framework for exploring interdisciplinary roles in a goals of care initiative. Support and recognition of provider role expansion in goals of care conversations was important for the adoption of a goals of care initiative. Actionable strategies, including multi-level leadership support and the use of interdisciplinary champions, facilitate role change and have potential to strengthen uptake of a goals of care initiative.

Young adults understanding and readiness to engage with palliative care: extending the reach of palliative care through a public health approach: a qualitative study

BACKGROUND

Moving palliative care from a solely clinical focus to a more population based and community orientated approach is the hallmark of a much advocated public health approach to palliative care. Young adults are a vital cohort of the public, yet their understanding of palliative care has not been investigated. This study aimed to explore young adults' understanding of palliative care and identify factors that influence their engagement.

METHODS

A purposive sample of young adults (n = 24) aged 18-29 years were recruited from one UK University. Semi-structured interviews were undertaken face to face or via telephone or Skype between November 2017 and February 2018. Thematic analysis using a framework approach and underpinned by a socioecological perspective was used to analyse the interviews.

RESULTS

Three thematic categories were identified relating to intrapersonal and interpersonal influences, cultural and social influences and organisational and public policy influences. Palliative care was understood as supportive comfort care, delivered in the absence of cure, associated with the end of life and specifically focused on death and dying. Negative attitudes related to the context of care, which represented a static and hopeless situation. Whilst some reported positive attitudes, potential engagement was seen to be governed by a lack of knowledge and protective cultural norms. In terms of demonstrating readiness to engage with palliative care, participants requested clear information and suggested a normalising of palliative care through the education system.

CONCLUSION

Young adults in this study were ready to find out more about palliative care and identified social media as a platform upon which to engage this population. However, their perception of a society that views palliative care as a subject for those directly affected, creates a barrier to engagement. This study identified the ingredients of a public health message and mediums for disseminating the message. However, findings also suggest that a cultural shift is required to recognise the potential of engaging young adults in health issues that cross the life span, empowering them not only as individuals but as vital members of community and society.

Palliative and End-of-Life Care in a Small Caribbean Country: A Mortality Follow-back Study of Home Deaths

CONTEXT

Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings.

OBJECTIVES

To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received.

METHOD

A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death.

RESULTS

Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member.

CONCLUSION

The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.

Hospital patients' perspectives on what is essential to enable optimal palliative care: A qualitative study

BACKGROUND

The majority of expected deaths in high income countries occur in hospital where optimal palliative care cannot be assured. In addition, a large number of patients with palliative care needs receive inpatient care in their last year of life. International research has identified domains of inpatient care that patients and carers perceive to be important, but concrete examples of how these might be operationalised are scarce, and few studies conducted in the southern hemisphere.

AIM

To seek the perspectives of Australian patients living with palliative care needs about their recent hospitalisation experiences to determine the relevance of domains noted internationally to be important for optimal inpatient palliative care and how these can be operationalised.

DESIGN

An exploratory qualitative study using semi-structured interviews.

SETTING/PARTICIPANTS

Participants were recruited through five hospitals in New South Wales, Australia.

RESULTS

Twenty-one participants took part. Results confirmed and added depth of understanding to domains previously identified as important for optimal hospital palliative care, including: Effective communication and shared decision making; Expert care; Adequate environment for care; Family involvement in care provision; Financial affairs; Maintenance of sense of self/identity; Minimising burden; Respectful and compassionate care; Trust and confidence in clinicians and Maintenance of patient safety. Two additional domains were noted to be important: Nutritional needs; and Access to medical and nursing specialists.

CONCLUSIONS

Taking a person-centred focus has provided a deeper understanding of how to strengthen inpatient palliative care practices. Future work is needed to translate the body of evidence on patient priorities into policy reforms and practice points.

End-of-life conversation from both sides of the bed: voices of family and staff

PURPOSE

Prolonged living with chronic illness and disability expands the discussion of end-of-life conversation because of the complex role of intercommunication among patient, family, and healthcare staff. Little is known about such interaction from participants' different perspectives. This qualitative case study examined end-of-life conversation among patient, family, and staff during long-term hospitalization in a neurological rehabilitation department.

METHODS

After the patient's death, 18 participants responded to in-depth semi-structured interviews: 16 healthcare staff and two family members (the patient's wife and brother). In addition, we used the wife's autoethnographic documentation of her experiences during end-of-life conversation.

RESULTS

Thematic analysis produced three themes: (1) The Rehabilitation Department's Mission - Toward Life or Death? (2) The Staff's Perception of the Patient; (3) Containing Death: End-of-life Conversation from Both Sides of the Bed. These themes represented participants' different perspectives in the intercommunication in overt and covert dialogues, which changed over time. Death's presence-absence was expressed by movement between clinging to life and anticipating death.

CONCLUSION

The study findings emphasize the importance of practitioners' training to accept and openly discuss death as an inseparable part of life-long disability, and the implementation of this stance during end-of-life care via sensitive conversations with patients and their families.IMPLICATIONS FOR REHABILITATIONIt is vital for rehabilitation professionals to be trained to process and accept end-of-life issues as a natural and inseparable part of the life discourse among people with disabilities and their families.Rehabilitation professionals need to acquire tools to grasp the spoken and unspoken issues related to life and death, and to communicate their impressions and understandings with people with disabilities and their families.Rehabilitation professionals need to encourage an open dialogue when communicating with people with disabilities and their families on processes related to parting and death.

Factors associated with overall satisfaction with care at the end-of-life: Caregiver voices in New Zealand

In New Zealand, as in other industrialised societies, an ageing population has led to an increased need for palliative care services. A cross-sectional postal survey of bereaved carers was conducted in order to describe both bereaved carer experience of existing services in the last 3 months of life, and to identify factors associated with overall satisfaction with care. A self-complete questionnaire, using a modified version of the Views of Informal Carers - Evaluation of Services (VOICES) instrument was sent to 4,778 bereaved carers for registered deceased adult (>18yrs) patients in one district health board (DHB) for the period between November 2015 and December 2016. Eight hundred and twenty-six completed questionnaires were returned (response rate = 21%). The majority of respondents (83.8%) rated their overall satisfaction with care (taking all care during the last 3 months into account), as high. However, satisfaction varied by care setting. Overall satisfaction with care in hospice was significantly higher compared to other settings. Additionally, patients who died in hospice were more likely to be diagnosed with cancer and under 65 years of age. The factors associated with overall satisfaction with care in the last 2 days of life were: caregiver perceptions of treatment with dignity and respect; adequate privacy; sufficient pain relief and decisions in line with the patient's wishes. A more in-depth exploration is required to understand the quality of, and satisfaction with, care in different settings as well as the factors that contribute to high/low satisfaction with care at the end-of-life.

Nurses' knowledge about palliative care and attitude towards end- of-life care in public hospitals in Wollega zones: A multicenter cross-sectional study

BACKGROUND

Palliative care is nowadays essential in nursing care, due to the increasing number of patients who require attention in the final stages of their life. Lack of knowledge of and negative attitude palliative care among nurses is one of the most common barriers to quality palliative care. This study, therefore, aimed to assess nurses' knowledge about palliative care and attitude toward end-of-life care in public hospitals in Wollega zones, Ethiopia.

METHODS

A multicenter institutional-based cross-sectional study design was employed to collect data from 372 nurses working in public hospitals in Wollega zones from October 02-22, 2019. A self-administered questionnaire with three different parts: Demographic characteristics of nurses, the Palliative Care Quiz for Nursing (PCQN), and the Frommelt Attitudes Towards Care of the Dying (FATCOD). SPSS version 21 was used for analysis used for data analysis. The binary logistic regression test was used for analysis at p < 0.05.

FINDINGS

Our final sample size was 422 nurses (response rate = 88%). With the mean total PCQN scores (9.34), the majority of them showed an inadequate level of knowledge about palliative care. The mean total FATCOD scores (79.58) displayed a positive attitude toward end-of-life care, with 52% of respondents eager to care for a dying person and their family. Nurses who had PC service experience [AOR = 1.94 CI (1.10-3.42), p = 0.02] and had ever attended training/lecture on PC [AOR = 1.87 CI (1.01-3.46), p = 0.04] were independently associated with nurses' knowledge about PC. Similarly, nurses who had no PC service experience [AOR = 0.41, CI (0.21-0.79), p = 0.008], who read articles/brochures about PC [AOR = 1.94, CI (1.11-3.39), p = 0.01] and had provided care for a smaller number of terminally ill patients [AOR = 1.74, CI (1.01-2.97), p = 0.04] were significantly associated with nurses' attitude towards end-of-life care.

CONCLUSION

The study highlighted that nurses' knowledge about palliative care is inadequate, and showed a less favorable attitude toward end-of-life care. The findings also provide evidence for greater attentions and resources should be directed towards educating and supporting nurses caring for patients with palliative care needs in Wollega Zones.

What do positive and negative experiences of patients, relatives, general practitioners, medical assistants, and nurses tell us about barriers and supporting factors in outpatient palliative care? A critical incident interview study

Background: The strengthening of the general practitioners’ (GPs’) role in palliative care (PC) has been identified as a top priority in order to improve PC in Germany. This study aims at exploring positive and negative experiences in PC in Germany from the perspectives of patients, relatives, and health care professionals in a primary care setting.

Methods: Between March 2017 and August 2017, a total of 16 interviews with patients, relatives, GPs, medical assistants, and nurses were conducted. The Critical Incident Technique (CIT) was used to explore factors that influence excellent versus undesirable events in PC provision. Two researchers independently defined and counted critical incidents (CIs) from interview transcripts, performed a thematic analysis, and clustered the CIs into dimensions.

Results: In summary, 16 interviews contained 280 CIs, divided into 130 positive and 150 negative CIs. The thematic analysis resulted in seven content domains, with each including positive and negative CIs, respectively: 1) way of care provision, 2) availability of care providers, structures, medication, and aids, 3) general formal conditions of care provision, 4) bureaucracy, 5) working practices in health care teams, 6) quality and outcome of care provision, and 7) communication.

Conclusions: The results raise awareness for the aspects that lead to successful or undesirable PC experiences, observed from different perspectives. They open up the potential for primary PC improvement. Future research will facilitate development and implementation of more tailored interventions in order to improve generalists’ PC.

Feasibility of the PalliSupport care pathway: results from a mixed-method study in acutely hospitalized older patients at the end of life

BACKGROUND

A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial.

METHODS

A mixed-method feasibility study was conducted at one hospital with affiliated primary care. Patients were ≥ 60 years and acutely hospitalized. The intervention consisted of (1) training on early identification of the palliative phase and end of life conversations, (2) involvement of a transitional palliative care team during admission and post-discharge and (3) intensified collaboration between care settings. Outcomes were feasibility of recruitment, data collection, patient burden and protocol adherence. Experiences of 14 professionals were assessed through qualitative interviews.

RESULTS

Only 16% of anticipated participants were included which resulted in difficulty assessing other feasibility criteria. The qualitative analysis identified misunderstandings about palliative care, uncertainty about professionals' roles and difficulties in initiating end of life conversations as barriers. The training program was well received and professionals found the intensified collaboration beneficial for patient care. The patients that participated experienced low burden and data collection on primary outcomes and protocol adherence seems feasible.

DISCUSSION

This study highlights the importance of performing a feasibility study prior to embarking on effectiveness studies. Moving forward, the PalliSupport care pathway will be adjusted to incorporate a more active recruitment approach, additional training on identification and palliative care, and further improvement on data collection.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nursing competencies across different levels of palliative care provision: A systematic integrative review with thematic synthesis

BACKGROUND

Palliative care exists in diverse healthcare settings. Nurses play a crucial role in its provision. Different levels of palliative care provision and education have been recognized in the literature. Therefore, nurses need a set of various competencies to provide high-quality palliative care.

AIMS

To systematically synthesize the empirical evidence of (1) nursing competencies needed in palliative care and (2) whether these competencies differ across the level of palliative care.

DESIGN

Systematic integrative review with thematic synthesis. Prospero: CRD42018114869.

DATA SOURCES

CINAHL, PubMed, Academic Search Premier, Scopus and Medic databases. Studies on nursing competencies linked to palliative care reported in English, Swedish, Finnish, Spanish, Portuguese or German were considered. Search terms: 'palliative care or hospice care or end-of-life care', 'competency or professional competence or skills' and 'nursing'. Articles were independently screened and reviewed by two researchers. Quality appraisal was conducted following Hawker's criteria.

RESULTS

A total of 7454 articles were retrieved, 21 articles were included in the analysis. Six diverse nursing competencies dimensions, namely leadership, communication, collaboration, clinical, ethico-legal and psycho-social and spiritual were identified. The reports rarely defined the level of palliative care and covered a wide array of healthcare settings.

CONCLUSION

Nurses need a wide range of competencies to provide quality palliative care. Few studies focused on which competencies are relevant to a specific level of palliative care. Further research is needed to systematize the nursing competencies and define which nursing competencies are central for different levels of palliative care to enhance palliative care development, education and practice.

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

BACKGROUND

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

AIM

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

Nurses practice towards palliative care in Shire Endasilasie health facilities, Northern Ethiopia: a cross-sectional study

Introduction

The public health strategy of the World Health Organization for palliative care is to increase access to palliative care services by integrating it with the healthcare systems. Therefore, the value of palliative care service provision by nurses who deliver the majority of care to chronical patients is an important issue. The objective of the study is assessing nurses' practice of palliative care.

Methods

A facility based cross-sectional study was carried out among 278 nurses working in governmental health facilities of Shire Endasilasie town, Tigray region, Ethiopia from February to June 2018. The questionnaire was revised based on the findings of the pre-test. The collected data was checked for its completeness, consistency, and accuracy before analysis. Data were entered and analyzed using SPSS version 22. The final result was reported using text and tables.

Results

A total of 278 nurses were included in the study and the response rate was 100%. The majority of the participants (71.9%) were females and the mean age of the respondents was 32.08 years (range from 20 to 60). Approximately two-thirds (74.8%) of the respondents had poor knowledge of palliative care practice. Half of the study participants reported emotional support gained as primary psychological support. Commonly used drugs for severe pain were paracetamol or ibuprofen 202 (72.2%) and 47.8% nurses focus on quality patient pain assess.

Conclusion

The majority of the nurses had a poor practice of palliative care.

Palliative care provision in long-term care facilities differs across Europe: Results of a cross-sectional study in six European countries (PACE)

BACKGROUND

While the need for palliative care in long-term care facilities is growing, it is unknown whether palliative care in this setting is sufficiently developed.

AIM

To describe and compare in six European countries palliative care provision in long-term care facilities and to assess associations between patient, facility and advance care planning factors and receipt and timing of palliative care.

DESIGN

Cross-sectional after-death survey regarding care provided to long-term care residents in Belgium, England, Finland, Italy, the Netherlands and Poland. Generalized estimating equations were used for analyses.

SETTING/PARTICIPANTS

Nurses or care assistants who are most involved in care for the resident.

RESULTS

We included 1298 residents in 300 facilities, of whom a majority received palliative care in most countries (England: 72.6%-Belgium: 77.9%), except in Poland (14.0%) and Italy (32.1%). Palliative care typically started within 2 weeks before death and was often provided by the treating physician (England: 75%-the Netherlands: 98.8%). A palliative care specialist was frequently involved in Belgium and Poland (57.1% and 86.7%). Residents with cancer, dementia or a contact person in their record more often received palliative care, and it started earlier for residents with whom the nurse had spoken about treatments or the preferred course of care at the end of life.

CONCLUSION

The late initiation of palliative care (especially when advance care planning is lacking) and palliative care for residents without cancer, dementia or closely involved relatives deserve attention in all countries. Diversity in palliative care organization might be related to different levels of its development.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Palliative care for people with non-malignant respiratory disease and their carers: a review of the current evidence

Background

Internationally, non-malignant respiratory disease is on the increase. However, although palliative care is recommended as an appropriate healthcare option for this client group, evidence suggests that these patients and their carers do not receive the same standards of palliative care as patients with a malignant lung condition.

Aim

The aim of this review was to provide a critical overview of the current evidence base in relation to the palliative service provision for people with non-malignant respiratory disease and their carers.

Methods

A review of the literature was conducted in July 2015 and updated in October 2017 and focused on the palliative care service provision for patients with interstitial lung disease, chronic obstructive pulmonary disease and bronchiectasis.

Results

In total, 71 empirical studies were included in the review and grouped into two main themes: patient and carer's bio-psychosocial symptom needs and management, and palliative care service provision for patients with non-malignant respiratory disease and their carers.

Conclusion

The majority of palliative research focuses on patients with a diagnosis of chronic obstructive pulmonary disease. A deeper insight is required into the palliative service provision experienced by those with other forms of non-malignant respiratory disease such as bronchiectasis and interstitial lung disease.

Dataset on the nurses' knowledge, attitude and practice towards palliative care

When a patient enters the end stage of life threatening disease like cancer, treatment of pain and other symptoms must be considered to preserve quality of life (Gielen et al., 2011) [1]. Nurses have an important role in the care of patients who suffered from life threatening diseases. End of life cares is one of the routine activities of nurses (Gott et al., 2012) [2]. We surveyed knowledge, attitude and practice of nurses who worked in the hospitals of Neyshabur University of Medical Sciences towards palliative care from January 2016 to May 2016. A self-administered Persian questionnaire was used for data collection. The attitude scale was adopted from Frommelt Attitude toward Care of the Dying (Frommelt, 1991) and the knowledge questions were adopted from the Palliative Care Quiz for Nursing (Ross et al., 1996). The practice questions were also adopted from different related studies. Data analysis was performed by SPSS Statistics software for windows version 16. Our study showed that majority of nurses had favorable attitude but poor knowledge and practice towards palliative care. The results emphasize the importance and need for developing palliative care services in our hospitals.

[Nurses' perspectives on outpatient palliative care in Vorarlberg, Austria]

BACKGROUND

Due to the demographic development the need for palliative care in the outpatient setting will increase and challenge general practitioners and community nurses.

AIM

This study investigated the state of outpatient palliative care in Vorarlberg, Austria from the perspective of outpatient community nurses. The key points of the survey covered the burden of symptoms suffered by palliative patients. Another key focus was the cooperation and communication between community nurses and general practitioners.

METHODS

Between 8 February and 7 March 2016 all 50 community-based nursing services in Vorarlberg were invited to participate in an online survey designed to estimate outpatient palliative care. The survey collected quantitative and descriptive data and 38 nursing services returned the questionnaire (76 %).

RESULTS

According to community-based nurses, the proportion of patients in need of palliative care was 5.7 %. This assessment of needs correlates well with the proportion of personnel qualified in palliative care (p = 0.02). Nursing personnel estimated a high prevalence of symptom burden (76 %). Communication between outpatient nursing personnel and general practitioners relied primarily on telephone calls (79-90 %), less on joint rounds (13-21 %) and case reviews (26-45 %). According to 63 % of the nursing personnel the rate of hospitalization could be reduced with better interprofessional cooperation.

DISCUSSION

Symptom burden in the outpatient setting was similar to that of patients being cared for in hospitals. Healthcare personnel in general palliative care should be adequately qualified. The quality of communication via telephone calls should be critically examined in further studies.

Duration and determinants of hospice-based specialist palliative care: A national retrospective cohort study

BACKGROUND

Understanding service provision for patients with advanced disease is a research priority, with a need to identify barriers that limit widespread integration of palliative care.

AIM

To identify patient and organisational factors that influence the duration of hospice-based palliative care in the United Kingdom prior to death.

DESIGN

This is a retrospective cohort study.

SETTING/PARTICIPANTS

A total of 64 UK hospices providing specialist palliative care inpatient beds and community services extracted data for all adult decedents (aged over 17 years) with progressive, advanced disease, with a prior referral (e.g. inpatient, community teams, and outpatient) who died between 1 January 2015 and 31 December 2015. Data were requested for factors relating to both the patient and hospice site.

RESULTS

Across 42,758 decedents, the median time from referral to death was 48 days. Significant differences in referral to death days were found for those with cancer (53 days) and non-cancer (27 days) ( p < 0.0001). As age increases, the median days from referral to death decreases: for those under 50 years (78 days), 50-74 years (59 days), and 75 years and over (39 days) ( p = 0.0001). An adjusted multivariable negative binomial model demonstrated increasing age persisting as a significant predictor of fewer days of hospice care, as did being male, having a missing ethnicity classification and having a non-cancer diagnosis ( p < 0.001).

CONCLUSION

Despite increasing rhetoric around early referral, patients with advanced disease are receiving referrals to hospice specialist palliative care very late in their illness trajectory. Age and diagnosis persist as determinants of duration of hospice specialist palliative care before death.

Prepared for end-of-life care: a concept analysis

BACKGROUND

Recent international documents have highlighted the importance of preparing the nursing workforce for end of life care. However, these documents do not make clear what prepared in the context of end-of-life care actually means. Searching the literature failed to retrieve any papers defining prepared in this context.

AIM

A concept analysis, using Walker and Avant's model, was conducted to help address this gap in the knowledge base.

RESULTS

From this analysis many attributes and antecedents were synthesised. These include that a prepared nurse would be confident to: assess the dying patient, communicate with empathy, identify and manage symptoms, recognise and deal with death and dying, understand the holistic elements of dying, be comfortable with the effects of loss and bereavement on patients and self, and be self-competent.

CONCLUSIONS

From this analysis, a clearer idea of what is needed to prepare nurses for end-of-life care is offered and suggestions for future research are made.

Burnout, compassion fatigue and psychological capital: Findings from a survey of nurses delivering palliative care

BACKGROUND

Ageing populations worldwide and a concomitant increase in chronic conditions translates into an increased demand for the delivery of palliative and end of life care by nurses. This increasing demand for palliative care provision may produce stressors resulting in negative outcomes such as burnout and compassion fatigue.

AIM

The purpose of this study was to explore burnout and compassion fatigue, as well as potential protective factors, among nurses in New Zealand.

METHODS

An online survey was conducted with 256 registered nurses (between January 2016 and February 2017) recruited through nursing organisations and a large tertiary level hospital. Data analysis consisted of descriptive statistics, multivariate analysis of variance, Pearson correlations, and hierarchical multiple regression.

RESULTS

Psychological empowerment and the commitment and challenge components of psychological hardiness significantly predicted lower scores for the burnout while previous palliative care education and challenge predicted lower scores for the secondary traumatic stress component of compassion fatigue. Significant predictors of compassion satisfaction included previous palliative care education, psychological empowerment and both the commitment and challenge components of psychological hardiness.

CONCLUSION

Nurses draw upon unique combinations of "psychological capital" to deal with caring for patients with life-limiting illnesses. Any interventions to increase nurse palliative care education uptake must be tailored to develop and support these internal resources.

Exploring Education and Training Needs in Palliative Care among Family Physicians in Mumbai: A Qualitative Study

Context:

Patients with chronic life-limiting conditions on palliative care (PC) prefer to be treated at home. Medical care by family physicians (FPs) reduces demand on costly and busy hospital facilities. Working of PC team in collaboration with FPs is thus helpful in home-based management of patients.

Aims:

This study aimed at exploring the extent of knowledge of FPs about PC and the need for additional training.

Settings and Design:

Semi-structured interviews were conducted with ten FPs from two suburbs of Mumbai, currently served by home care services of a tertiary cancer care center.

Subjects and Methods:

Data were digitally recorded, transcribed, and analyzed using exploratory analysis followed by content analysis to develop thematic codes.

Results and Conclusions:

FPs perceive PC as symptom control and psychological support helpful in managing patients with advanced life-limiting illnesses. Further training would help them in PC provision. Such training programs should preferably focus on symptom management and communication skills. There is a need for further research in designing a training module for FPs to get better understanding of the principles of PC.

The "ARIANNA" Project: An Observational Study on a Model of Early Identification of Patients with Palliative Care Needs through the Integration between Primary Care and Italian Home Palliative Care Units

OBJECTIVE

The aim of this study was to illustrate the characteristics of patients with palliative care (PC) needs, early identified by general practitioners (GPs), and to analyze their care process in home PC services.

BACKGROUND

Early identification and service integration are key components to providing quality palliative care (PC) services ensuring the best possible service for patients and their families. However, in Italy, PC is often provided only in the last phase of life and for oncological patients, with a fragmented service.

METHODS

Multicenter prospective observational study, lasting in total 18 months, implemented in a sample of Italian Home Palliative Care Units (HPCUs), enrolling and monitoring patients with limited life expectancy, early identified by 94 GPs. The study began on March 1, 2014 and ended on August 31, 2015.

RESULTS

Nine hundred thirty-seven patients, out of a total pool of 139,071, were identified by GPs as having a low life expectancy and PC needs. Of these, 556 (59.3%) were nononcological patients. The GPs sent 433 patients to the HPCUs for multidimensional assessment, and 328 (75.8%) were placed in the care of both settings (basic or specialist). For all patients included in the study, both oncological and nononcological patients, there was a high rate of death at home, around 70%.

DISCUSSION

This study highlights how a model based on early identification, multidimensional evaluation, and integration of services can promote adequate PC, also for noncancer patients, with a population-based approach.

Impact of the Macmillan specialist Care at Home service: a mixed methods evaluation across six sites

BACKGROUND

The Midhurst Macmillan Specialist Palliative Care at Home Service was founded in 2006 to improve community-based palliative care provision. Principal components include; early referral; home-based clinical interventions; close partnership working; and flexible teamwork. Following a successful introduction, the model was implemented in six further sites across England. This article reports a mixed methods evaluation of the implementation across these 'Innovation Centres'. The evaluation aimed to assess the process and impact on staff, patients and carers of providing Macmillan Specialist Care at Home services across the six sites.

METHODS

The study was set within a Realist Evaluation framework and used a longitudinal, mixed methods research design. Data collection over 15 months (2014-2016) included: Quantitative outcome measures - Palliative Performance Scale [PPS] and Palliative Prognostic Index [PPI] (n = 2711); Integrated Palliative Outcome Scales [IPOS] (n = 1157); Carers Support Needs Assessment Tool [CSNAT] (n = 241); Views of Informal Carers -Evaluation of Services [VOICES-SF] (n = 102); a custom-designed Service Data Tool [SDT] that gathered prospective data from each site (n = 88). Qualitative data methods included: focus groups with project team and staff (n = 32 groups with n = 190 participants), and, volunteers (n = 6 groups with n = 32 participants). Quantitative data were analysed using SPPS Vs. 21 and qualitative data was examined via thematic analysis.

RESULTS

Comparison of findings across the six sites revealed the impact of their unique configurations on outcomes, compounded by variations in stage and mode of implementation. PPS, PPI and IPOS data revealed disparity in early referral criteria, complicated by contrasting interpretations of palliative care. The qualitative analysis, CSNAT and VOICES-SF data confirmed the value of the Macmillan model of care but uptake of specialist home-based clinical interventions was limited. The Macmillan brand engendered patient and carer confidence, bringing added value to existing services. Significant findings included better co-ordination of palliative care through project management and a single referral point and multi-disciplinary teamwork including leadership from consultants in palliative medicine, the role of health care assistants in rapid referral, and volunteer support.

CONCLUSIONS

Macmillan Specialist Care at Home increases patient choice about place of death and enhances the quality of end of life experience. Clarification of key components is advocated to aid consistency of implementation across different sites and support future evaluative work.

Primary palliative Care in General Practice - study protocol of a three-stage mixed-methods organizational health services research study

Background

The focus of this project is on improving the provision of primary palliative care (PC) by general practitioners (GPs). While approximately 10–15% of the incurable, seriously ill or dying people will be in need of specialist PC, the vast majority can be adequately treated within generalist care. The strengthening of the GP’s role in PC, as well as ensuring close collaboration between specialist PC services and GPs have been identified as top priorities for the improvement of PC in Germany. Despite healthcare policy actions, diverse obstacles still exist to successful implementation of primary PC on a structural, process, and economic level. Therefore, this project aims at addressing barriers and facilitators to primary PC delivery in general practice in Germany.

Methods

The study follows a three-step approach; first, it aims at systematically analyzing barriers and facilitators to primary PC provision by GPs. Second, based on these outcomes, a tailored intervention package will be developed to enhance the provision of primary PC by GPs. Third, the intervention package will be implemented and evaluated in practice. The expected outcome will be an evidence-based model for successful implementation of primary PC delivery tailored to the German healthcare system, followed by a strategic action plan on how to improve current practice both on a local level and nationally.

Discussion

The first step of the project has been partly completed at the time of writing. The chosen methodologies of four sub-projects within this first step have opened up different advantages and disadvantages for the data collection. In sum of all sub-projects, the different methodologies and target groups contributed valuable information to the systematic analysis of barriers and facilitators to primary PC provision by GPs.

Trial registration

The study (BMBF-FK 01 GY 1610) was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00011821; date of registration: December 04th 2017) and at the German Register of health care research (Versorgungsforschung Deutschland - Datenbank) (Registration N° VfD_ALLPRAX_16_003817; date of registration: March 30th 2017).

The impact of early palliative care on the quality of care during the last days of life: what does the evidence say?

PURPOSE OF REVIEW

The aim of this review is to critically appraise the existing evidence on 'early palliative care' (EPC), discuss its relationship with advance care planning, and to reflect on the impact of EPC on the quality of care provided during the last days of life.

RECENT FINDINGS

There are indicators that EPC may help to avoid aggressive treatment, shorten hospital stay, improve overall quality of life, and to see more frequently dying and death at the preferred place of care.

SUMMARY

The evidence from randomized controlled trials supports the integration of palliative care early in the disease trajectory. However, in terms of outcomes and quality indicators for care in the last days of life, evidence is still lacking. Predominantly, when it comes to the outcomes which may be more difficult to assess, such as spiritual aspects, or the social network, for which more comprehensive information is needed. These outcomes should not be neglected in palliative care studies, particularly when they can provide meaningful information about patient and family adjustment, and focus on psychosocial aspects rather than physical symptom control.

Using the “Surprise Question” in Nursing Homes

Background:

The “Surprise Question” (SQ) is often used to identify patients who may benefit from a palliative care approach. The time frame of the typical question (a 12-month prognosis) may be unsuitable for identifying residents in nursing homes since it may not be able to differentiate between those who have a more imminent risk of death within a cohort of patients with high care needs.

Objective:

To examine the accuracy and acceptability of 3 versions of the SQ with shortened prognostication time frames (3 months, 6 months, and “the next season”) in the nursing home setting.

Design:

A prospective mixed-methods study.

Setting/Participants:

Forty-seven health-care professionals completed the SQ for 313 residents from a nursing home in Ontario, Canada. A chart audit was performed to evaluate the accuracy of their responses. Focus groups and interviews were conducted to examine the participants’ perspectives on the utility of the SQ.

Results:

Of the 301 residents who were included in the analysis, 74 (24.6%) deaths were observed during our follow-up period. The probability of making an accurate prediction was highest when the seasonal SQ was used (66.7%), followed by the 6-month (58.9%) and 3-month (57.1%) versions. Despite its high accuracy, qualitative results suggest the staff felt the seasonal SQ was ambiguous and expressed discomfort with its use.

Conclusion:

The SQ with shortened prognostication periods may be useful in nursing homes and provides a mechanism to facilitate discussions on palliative care. However, a better understanding of palliative care and increasing staff’s comfort with prognostication is essential to a palliative care approach.

Specialist palliative care nursing and the philosophy of palliative care: a critical discussion

Nursing is the largest regulated health professional workforce providing palliative care across a range of clinical settings. Historically, palliative care nursing has been informed by a strong philosophy of care which is soundly articulated in palliative care policy, research and practice. Indeed, palliative care is now considered to be an integral component of nursing practice regardless of the specialty or clinical setting. However, there has been a change in the way palliative care is provided. Upstreaming and mainstreaming of palliative care and the dominance of a biomedical model with increasing medicalisation and specialisation are key factors in the evolution of contemporary palliative care and are likely to impact on nursing practice. Using a critical reflection of the authors own experiences and supported by literature and theory from seminal texts and contemporary academic, policy and clinical literature, this discussion paper will explore the influence of philosophy on nursing knowledge and theory in the context of an evolving model of palliative care.