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Blomberg K, Lindqvist O, Harstäde CW, Söderman A, Östlund U. Translating the Patient Dignity Inventory. Int J Palliat Nurs 2019; 25:334-343. [DOI: 10.12968/ijpn.2019.25.7.334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: The Patient Dignity Inventory (PDI) is based on an empirically-driven dignity model that has been developed and used for clinically assessing the various sources of dignity-related distress. In a recent review, it received the highest score as a useful instrument in both practice and research in palliative care. The PDI has been adapted to and validated for use in various countries, but not yet Sweden. Aims: To translate the PDI into Swedish, including cultural adaptation for clinical use. Methods: A multi-step process of translation, negotiated consensus, expert group discussion (n=7: four invited experts and three researchers) and cognitive interviewing (n=7: persons with palliative care needs). Findings: Discussion, by the expert reviewers, of both linguistic and cultural issues regarding the content and readability of the translated Swedish version resulted in revisions of items and response alternatives, focusing mainly on semantic, conceptual, and experiential equivalence. A pilot version for cognitive interviews was produced. The analysis of data showed that most of the items were judged to be relevant by the persons with palliative care needs. Conclusion: The process of translation and adaptation added clarity and consistency. The Swedish version of the PDI can be used in assessing dignity-related distress. The next step will be to test this Swedish version for psychometric properties in a larger group of patients with palliative care needs before use in research.
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Affiliation(s)
- Karin Blomberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | | | - Carina Werkander Harstäde
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar/Växjö, Sweden
| | - Annika Söderman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Ulrika Östlund
- Center for Research & Development, Uppsala University/Region Gävleborg, Gävle, Sweden Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Nie M, Liu C, Pan YC, Jiang CX, Li BR, Yu XJ, Wu XY, Zheng SN. Development and evaluation of oral Cancer quality-of-life questionnaire (QOL-OC). BMC Cancer 2018; 18:523. [PMID: 29724176 PMCID: PMC5934940 DOI: 10.1186/s12885-018-4378-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/16/2018] [Indexed: 11/26/2022] Open
Abstract
Background In this study scales and items for the Oral Cancer Quality-of-life Questionnaire (QOL-OC) were designed and the instrument was evaluated. Methods The QOL-OC was developed and modified using the international definition of quality of life (QOL) promulgated by the European Organization for Research and Treatment of Cancer (EORTC) and analysis of the precedent measuring instruments. The contents of each item were determined in the context of the specific characteristics of oral cancer. Two hundred thirteen oral cancer patients were asked to complete both the EORTC core quality of life questionnaire (EORTC QLC-C30) and the QOL-OC. Data collected was used to conduct factor analysis, test-retest reliability, internal consistency, and construct validity. Results Questionnaire compliance was relatively high. Fourteen of the 213 subjects accepted the same tests after 24 to 48 h demonstrating a high test-retest reliability for all five scales. Overall internal consistency surpasses 0.8. The outcome of the factor analysis coincides substantially with our theoretical conception. Each item shows a higher correlation coefficient within its own scale than the others which indicates high construct validity. Conclusions QOL-OC demonstrates fairly good statistical reliability, validity, and feasibility. However, further tests and modification are needed to ensure its applicability to the quality-of-life assessment of Chinese oral cancer patients. Electronic supplementary material The online version of this article (10.1186/s12885-018-4378-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Min Nie
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China.
| | - Chang Liu
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Yi-Chen Pan
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Chen-Xi Jiang
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Bao-Ru Li
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Xi-Jie Yu
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Xin-Yu Wu
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
| | - Shu-Ning Zheng
- The State Key Laboratory Breeding Base of Basic Science of Stomatology, Hubei Province & Key Laboratory of Oral Biomedicine (Wuhan University), Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan, 430079, Hubei, China
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Smets T, Onwuteaka-Philipsen BBD, Miranda R, Pivodic L, Tanghe M, van Hout H, Pasman RHRW, Oosterveld-Vlug M, Piers R, Van Den Noortgate N, Wichmann AB, Engels Y, Vernooij-Dassen M, Hockley J, Froggatt K, Payne S, Szczerbińska K, Kylänen M, Leppäaho S, Barańska I, Gambassi G, Pautex S, Bassal C, Deliens L, Van den Block L. Integrating palliative care in long-term care facilities across Europe (PACE): protocol of a cluster randomized controlled trial of the 'PACE Steps to Success' intervention in seven countries. BMC Palliat Care 2018. [PMID: 29530091 PMCID: PMC5848517 DOI: 10.1186/s12904-018-0297-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Several studies have highlighted the need for improvement in palliative care delivered to older people long-term care facilities. However, the available evidence on how to improve palliative care in these settings is weak, especially in Europe. We describe the protocol of the PACE trial aimed to 1) evaluate the effectiveness and cost-effectiveness of the ‘PACE Steps to Success’ palliative care intervention for older people in long-term care facilities, and 2) assess the implementation process and identify facilitators and barriers for implementation in different countries. Methods We will conduct a multi-facility cluster randomised controlled trial in Belgium, Finland, Italy, the Netherlands, Poland, Switzerland and England. In total, 72 facilities will be randomized to receive the ‘Pace Steps to Success intervention’ or to ‘care as usual’. Primary outcome at resident level: quality of dying (CAD-EOLD); and at staff level: staff knowledge of palliative care (Palliative Care Survey). Secondary outcomes: resident’s quality of end-of-life care, staff self-efficacy, self-perceived educational needs, and opinions on palliative care. Economic outcomes: direct costs and quality-adjusted life years (QALYs). Measurements are performed at baseline and after the intervention. For the resident-level outcomes, facilities report all deaths of residents in and outside the facilities over a previous four-month period and structured questionnaires are sent to (1) the administrator, (2) staff member most involved in care (3) treating general practitioner, and (4) a relative. For the staff-level outcomes, all staff who are working in the facilities are asked to complete a structured questionnaire. A process evaluation will run alongside the effectiveness evaluation in the intervention group using the RE-AIM framework. Discussion The lack of high quality trials in palliative care has been recognized throughout the field of palliative care research. This cross-national cluster RCT designed to evaluate the impact of the palliative care intervention for long-term care facilities ‘PACE Steps to Success’ in seven countries, will provide important evidence concerning the effectiveness as well as the preconditions for optimal implementation of palliative care in nursing homes, and this within different health care systems. Trial registration The study is registered at www.isrctn.com – ISRCTN14741671 (FP7-HEALTH-2013-INNOVATION-1 603111) Registration date: July 30, 2015.
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Affiliation(s)
- Tinne Smets
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium.
| | - Bregje B D Onwuteaka-Philipsen
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Rose Miranda
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lara Pivodic
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Marc Tanghe
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Hein van Hout
- Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Roeline H R W Pasman
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Mariska Oosterveld-Vlug
- EMGO Institute for Health and Care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, the Netherlands
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Anne B Wichmann
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yvonne Engels
- IQ healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Jo Hockley
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katherine Froggatt
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Sheila Payne
- International Observatory on End-of-Life Care, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Marika Kylänen
- National Institute for Health and Welfare, Helsinki, Finland
| | - Suvi Leppäaho
- National Institute for Health and Welfare, Helsinki, Finland
| | - Ilona Barańska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland.,Faculty of Health Sciences, Jagiellonian University Medical College, ul. Michałowskiego 12, 31-126, Kraków, Poland
| | | | - Sophie Pautex
- Hôpitaux Universitaires de Genève, University of Geneva, Geneva, Switzerland
| | - Catherine Bassal
- Center for the Interdisciplinary Study of Gerontology and Vulnerability (CIGEV), University of Geneva, Geneva, Switzerland
| | - Luc Deliens
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Lieve Van den Block
- Department of Family Medicine and Chronic Care, End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
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Bouça-Machado R, Titova N, Chaudhuri KR, Bloem BR, Ferreira JJ. Palliative Care for Patients and Families With Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:475-509. [PMID: 28554419 DOI: 10.1016/bs.irn.2017.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.
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Affiliation(s)
- Raquel Bouça-Machado
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Nataliya Titova
- Federal State Budgetary Educational Institution of Higher Education "N.I. Pirogov Russian National Research Medical University" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - K Ray Chaudhuri
- National Parkinson Foundation International Centre of Excellence, Kings College and Kings College Hospital, London, United Kingdom; Maurice Wohl Clinical Neuroscience Institute, Kings College, London, United Kingdom; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre (BRC) and Dementia Unit at South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Bas R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; CNS-Campus Neurológico Sénior, Torres Vedras, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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Bouça-Machado R, Rosário M, Alarcão J, Correia-Guedes L, Abreu D, Ferreira JJ. Clinical trials in palliative care: a systematic review of their methodological characteristics and of the quality of their reporting. BMC Palliat Care 2017; 16:10. [PMID: 28122560 PMCID: PMC5264484 DOI: 10.1186/s12904-016-0181-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Over the past decades there has been a significant increase in the number of published clinical trials in palliative care. However, empirical evidence suggests that there are methodological problems in the design and conduct of studies, which raises questions about the validity and generalisability of the results and of the strength of the available evidence. We sought to evaluate the methodological characteristics and assess the quality of reporting of clinical trials in palliative care. Methods We performed a systematic review of published clinical trials assessing therapeutic interventions in palliative care. Trials were identified using MEDLINE (from its inception to February 2015). We assessed methodological characteristics and describe the quality of reporting using the Cochrane Risk of Bias tool. Results We retrieved 107 studies. The most common medical field studied was oncology, and 43.9% of trials evaluated pharmacological interventions. Symptom control and physical dimensions (e.g. intervention on pain, breathlessness, nausea) were the palliative care-specific issues most studied. We found under-reporting of key information in particular on random sequence generation, allocation concealment, and blinding. Conclusions While the number of clinical trials in palliative care has increased over time, methodological quality remains suboptimal. This compromises the quality of studies. Therefore, a greater effort is needed to enable the appropriate performance of future studies and increase the robustness of evidence-based medicine in this important field. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0181-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raquel Bouça-Machado
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Madalena Rosário
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Joana Alarcão
- Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Leonor Correia-Guedes
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Daisy Abreu
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal. .,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal.
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Comparing Palliative Care in Care Homes Across Europe (PACE): Protocol of a Cross-sectional Study of Deceased Residents in 6 EU Countries. J Am Med Dir Assoc 2016; 17:566.e1-7. [DOI: 10.1016/j.jamda.2016.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022]
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Henoch I, Carlander I, Holm M, James I, Kenne Sarenmalm E, Lundh Hagelin C, Lind S, Sandgren A, Öhlén J. Palliative Care Research - A Systematic Review of foci, designs and methods of research conducted in Sweden between 2007 and 2012. Scand J Caring Sci 2015; 30:5-25. [DOI: 10.1111/scs.12253] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 05/06/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Ingela Henoch
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
| | - Ida Carlander
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
| | - Maja Holm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Inger James
- School of Health and Medical Sciences; Örebro University; Örebro Sweden
| | - Elisabeth Kenne Sarenmalm
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Research and Development Centre; Skaraborg Hospital; Skövde Sweden
| | - Carina Lundh Hagelin
- Medical Management Center; Department of Learning, Informatics, Management and Ethics; Karolinska Institutet; Stockholm Sweden
- Sophiahemmet University; Stockholm Sweden
- Research and Development Unit in Palliative care; Stockholms Sjukhem Foundation; Stockholm Sweden
| | - Susanne Lind
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
- Department of Neurobiology; Care Sciences and Society; Karolinska Institutet; Stockholm Sweden
| | - Anna Sandgren
- School of Health Sciences; Jönköping University; Jönköping Sweden
- Center for Collaborative Palliative Care; Department of Health and Caring Sciences; Linneaus University; Kalmar/Växjö Sweden
| | - Joakim Öhlén
- Institute of Health and Care Sciences; The Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- University of Gothenburg Centre for Person-Centred Care (GPCC); University of Gothenburg; Gothenburg Sweden
- Palliative Research Centre; Ersta Sköndal University College and Ersta Hospital; Stockholm Sweden
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Fosse A, Schaufel MA, Ruths S, Malterud K. End-of-life expectations and experiences among nursing home patients and their relatives--a synthesis of qualitative studies. PATIENT EDUCATION AND COUNSELING 2014; 97:3-9. [PMID: 24976628 DOI: 10.1016/j.pec.2014.05.025] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 05/20/2014] [Accepted: 05/30/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Synthesize research about patients' and relatives' expectations and experiences on how doctors can improve end-of-life care in nursing homes. METHODS We systematically searched qualitative studies in English in seven databases (Medline, Embase, PsycINFO, CINAHL, Ageline, Cochrane Systematic Reviews and Cochrane Trials). We included 14 publications in the analysis with meta-ethnography. RESULTS Patients and families emphasized the importance of health personnel anticipating illness trajectories and recognizing the information and palliation needed. Family members who became proxy decision-makers reported uncertainty and distress when guidance from health personnel was lacking. They worried about staff shortage and emphasized doctor availability. Relatives and health personnel seldom recognized patients' ability to consent, and patients' preferences were not always recognized. CONCLUSION Nursing home patients and their relatives wanted doctors more involved in end-of-life care. They expected doctors to acknowledge their preferences and provide guidance and symptom relief. PRACTICE IMPLICATIONS High-quality end-of-life care in nursing homes relies on organization, funding and skilled staff, including available doctors who are able to recognize illness trajectories and perform individualized Advance Care Planning.
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Affiliation(s)
- Anette Fosse
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | | | - Sabine Ruths
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kirsti Malterud
- Research Unit for General Practice, Uni Health Research, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Research Unit for General Practice, Copenhagen, Denmark
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