What is the role of specialist palliative care in an acute hospital setting? A qualitative study exploring views of patients and carers

The first casualty of COVID-19 for patients nearing death was human dignity: Understanding the experience of palliative care patients during the COVID-19 pandemic

The COVID-19 pandemic changed the way people lived, but also the way they died. It accentuated the physical, psychological, social, and spiritual vulnerabilities of patients approaching death. This study explored the lived experience of palliative inpatients during the pandemic. We conducted interviews with 22 palliative inpatients registered in a Canadian urban palliative care program, aimed to uncover how the pandemic impacted participants' experiences of approaching end-of-life. The reflexive thematic analysis revealed 6 themes: putting off going into hospital, the influence of the pandemic on hospital experience, maintaining dignity in care, emotional impact of nearing death, making sense of end-of-life circumstances and coping with end-of-life. Findings highlight the vulnerability of patients approaching death, and how that was accentuated during the pandemic. Findings reveal how the pandemic strained, threatened, and undermined human connectedness. These lived experiences of palliative inpatients offer guidance for future pandemic planning and strategies for providing optimal palliative care.

Uncovering Methods and Outcomes of Palliative Care for Geriatric Patients: A Scoping Review

Background

Palliative care is an integral part of care for patients with life-limited diseases that focuses on reducing symptoms and maintaining and increasing the quality of life (QoL) for patients and their families. Geriatric patients were more likely to receive palliative care and had unique needs compared to the general population. To improve the quality of palliative care, especially for geriatric patients, it is necessary to have a better understanding of methods and outcomes for geriatric patients when delivering palliative care.

Objective

This study aims to identify the methods and outcomes of palliative care in geriatric patients across the globe.

Methods

This scoping review was guided by Arksey and 'O Malley's framework and utilized the Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist for providing transparent reporting to the readers. EBSCO, PubMed, and Scopus databases were used to search the relevant articles with a publication range of 2013-2023. Thematic analysis was used to identify and summarize palliative care methods and outcomes for geriatric patients in this review.

Results

Twenty-one studies were included in this review, and it was found that there were many types of methods for delivering palliative care to geriatric patients. In both acute care settings and community settings, a wide range of methods for delivering palliative care to geriatric patients were identified. Outcomes of palliative care in geriatric patients in hospitals and community settings, were reduced pain, depressive symptoms and anxiety, edema, constipation, odds of in-hospital death, and increased spiritual well-being, QoL and well-being, being comfortable, patient readiness, place of death, sleep quality, and quality of dying.

Conclusion

Geriatric patients had a variety of methods and outcomes in palliative care. This study suggests that outcomes should be evaluated continuously after implementing methods for delivering palliative care to geriatric patients.

Perceptions and Knowledge Regarding Medical Situations at the End of Life among Older Adults in Switzerland

Background: Perceptions and knowledge regarding end-of-life health and health care can influence individuals' advance care planning, such as the completion and content of advance directives. Objectives: To assess older adults' perceptions of medical end-of-life situations in Switzerland along with their accuracy and corresponding associations with sociodemographic characteristics. Design: This is an observational study. Setting/study subjects: A nationally representative sample of adults aged 58 years and older who participated in wave 8 (2019/2020) of the Swiss part of the Survey of Health, Ageing, and Retirement in Europe (cooperation rate: 94.3%). Measurements: Subjective likelihood of 11 end-of-life situations on a 4-point scale: very unlikely (0-25%), rather unlikely (26%-50%), rather likely (51%-75%), and very likely (76%-100%). Results: Older adults' perceptions of end-of-life medical situations in Switzerland were rather heterogeneous and often inaccurate. Study subjects overestimated the success of cardiopulmonary resuscitation, the utility of a fourth-line chemotherapy, of hospital admission for pneumonia for patients with advanced dementia, and for artificial nutrition and hydration in the dying phase, while underestimating the effectiveness of pain management in this situation. Less than 28% of older adults correctly assessed the likelihood of dying in a nursing home, hospital, or at home, respectively. Inaccurate views were more frequent in men (p < 0.01) and individuals with financial difficulties (p < 0.05), whereas adults aged 75+ years (p < 0.01) and respondents from the German-speaking part of Switzerland (p < 0.01) had more accurate perceptions. Conclusions: The wide variation and low accuracy of end-of-life perceptions suggest considerable scope for communication interventions about the reality of end-of-life health and health care in Switzerland.

The relationship between satisfaction with care and quality of life among family caregivers of of patients living with terminal cancer in general wards: a cross-sectional study

Background:

Family caregivers of terminal cancer patients have reported experiencing low quality of life (QOL). Satisfaction with care has gained attention as a factor that correlates with QOL.

Aim:

To examine the relationship between ‘satisfaction with care’ and QOL of family caregivers of patients with terminal cancer.

Methods:

The study used a cross-sectional design and included family caregivers of patients with terminal cancer in general wards. The authors assessed family caregivers’ QOL using the caregiver quality of life index-cancer; a multivariable regression analysis was conducted to identify the factors associated with QOL.

Findings:

A total of 51 family caregivers enrolled in the study. Their satisfaction with care and the months since their initial diagnosis were positively associated with a more positive QOL.

Conclusion:

Satisfaction with care is correlated with QOL among family caregivers of patients with terminal cancer in general wards. Enhancing family caregivers’ satisfaction with care may contribute to improving their QOL.

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

Physicians and nurses working in acute care settings, such as tertiary hospitals, are involved in various stages of critical and terminal care, ranging from diagnosis of life-threatening diseases to care for the dying. It is well known that critical and terminal care causes moral distress to healthcare professionals. This study aimed to explore moral distress in critical and terminal care in acute hospital settings by analyzing the experiences of physicians and nurses from various departments. Semi-structured in-depth interviews were conducted in two tertiary hospitals in South Korea. The collected data were analyzed using grounded theory. A total of 22 physicians and nurses who had experienced moral difficulties regarding critical and terminal care were recruited via purposive maximum variation sampling, and 21 reported moral distress. The following points were what participants believed to be right for the patients: minimizing meaningless interventions during the terminal stage, letting patients know of their poor prognosis, saving lives, offering palliative care, and providing care with compassion. However, family dominance, hierarchy, the clinical culture of avoiding the discussion of death, lack of support for the surviving patients, and intensive workload challenged what the participants were pursuing and frustrated them. As a result, the participants experienced stress, lack of enthusiasm, guilt, depression, and skepticism. This study revealed that healthcare professionals working in tertiary hospitals in South Korea experienced moral distress when taking care of critically and terminally ill patients, in similar ways to the medical staff working in other settings. On the other hand, the present study uniquely identified that the aspects of saving lives and the necessity of palliative care were reported as those valued by healthcare professionals. This study contributes to the literature by adding data collected from two tertiary hospitals in South Korea.

Impact of palliative care consult service in inpatient hospital setting: a systematic literature review

OBJECTIVES

Despite a number of studies on effectiveness of palliative care, there is a lack of complex updated review of the impact of in-hospital palliative care consult service. The objective is to update information on the impact of palliative care consult service in inpatient hospital setting.

METHODS

This study was a systematic literature review, following the standard protocols (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Joanna Briggs Institute tools) to ensure the transparent and robust review procedure. The effect of palliative care consult service was classified as being associated with improvement, no difference, deterioration or mixed results in specific outcomes. PubMed, Scopus, Academic Search Ultimate and SocINDEX were systematically searched up to February 2020. Studies were included if they focused on the impact of palliative care consult service caring for adult palliative care patients and their families in inpatient hospital setting.

RESULTS

After removing duplicates, 959 citations were screened of which 49 full-text articles were retained. A total of 28 different outcome variables were extracted. 18 of them showed positive effects within patient, family, staff and healthcare system domains. No difference was observed in patient survival and depression. Inconclusive results represented patient social support and staff satisfaction with care.

CONCLUSIONS

Palliative care consult service has a number of positive effects for patients, families, staff and healthcare system. More research is needed on factors such as patient spiritual well-being, social support, performance, family understanding of patient diagnosis or staff stress.

Severe pain at the end of life: a population-level observational study

BACKGROUND

Pain is a prevalent symptom at the end of life and negatively impacts quality of life. Despite this, little population level data exist that describe pain frequency and associated factors at the end of life. The purpose of this study was to explore the prevalence of clinically significant pain at the end of life and identify predictors of increased pain.

METHODS

Retrospective population-level cohort study of all decedents in Ontario, Canada, from April 1, 2011 to March 31, 2015 who received a home care assessment in the last 30 days of life (n = 20,349). Severe daily pain in the last 30 days of life using linked Ontario health administrative databases. Severe pain is defined using a validated pain scale combining pain frequency and intensity: daily pain of severe intensity.

RESULTS

Severe daily pain was reported in 17.2% of 20,349 decedents. Increased risk of severe daily pain was observed in decedents who were female, younger and functionally impaired. Those who were cognitively impaired had a lower risk of reporting pain. Disease trajectory impacted pain; those who died of a terminal illness (i.e. cancer) were more likely to experience pain than those with frailty (odds ratio 1.66).

CONCLUSION

Pain is a common fear of those contemplating end of life, but severe pain is reported in less than 1 in 5 of our population in the last month of life. Certain subpopulations may be more likely to report severe pain at the end of life and may benefit from earlier palliative care referral and intervention.

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

Background

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

Methods

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

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

Results

Patient Sample:

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

Findings from Interviews:

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

Conclusions

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

Experience and Views of Oncology and Palliative Care Professionals on a Corounding Model of Care for Inpatients With Advanced Cancer

BACKGROUND

Palliative care is associated with better outcomes in advanced cancer, but there is limited research comparing different models of palliative care delivery alongside oncology care. For inpatients with cancer, palliative care is mostly delivered through a consult service, primarily relying on oncologist-initiated referrals to a separate specialist palliative care team. In our hospital setting, we piloted a palliative care and oncology corounding model of care.

AIM

To explore the views and experience of oncology and palliative care professionals on the corounding model compared to an inpatient consult service.

DESIGN

A qualitative study nested within a pre-post study of the corounding model of care, with semistructured interviews using thematic analysis.

SETTING/PARTICIPANTS

Eleven doctors and nurses involved in the pilot corounding model were interviewed.

RESULTS

Two main themes emerged: (1) the efficiency of care delivery and (2) quality of patient care. The theme on the efficiency of care delivery was related to access to palliative care input, team communications, and parallel workflow. The quality of patient care was described in terms of holistic approach to cancer care and rapport building with patients and their families. Most participants acknowledged positive aspects of the corounding model, yet some minor concerns were reported, such as disagreements between oncology and palliative care professionals.

CONCLUSIONS

This study provides insights into the benefits and drawbacks of a corounding model of care for inpatients. The views of health-care professionals can be incorporated into the development of integrated oncology and palliative care models to improve care for patients with advanced cancer.

Do Korean Doctors Think a Palliative Consultation Team Would Be Helpful to Their Terminal Cancer Patients?

PURPOSE

Hospice and palliative care services (HPC) are not commonly utilized in Korea; however, palliative care teams (PCTs) have been found to be effective at addressing the shortcomings in HPC. In this study, we attempted to outline unmet palliative care needs of terminal cancer patients and the potential benefits of PCTs as perceived by doctors in Korea.

MATERIALS AND METHODS

We surveyed 474 doctors at 10 cancer-related academic conferences from June to November 2014 with a self-report questionnaire to assess their perceptions of end-of-life care needs and the expected effects of PCTs on caring for terminal cancer patients. Among those surveyed, 440 respondents who completed the entire questionnaire were analyzed.

RESULTS

In all domains, fewer participants reported satisfaction with palliative care services than those reporting needs (p < 0.001). The surveyed participants also reported difficulties with a shortage of time for treatment, psychological burden, lack of knowledge regarding hospice care, lengths of stay, and palliative ward availability. Multivariate logistic regression analysis revealed that female doctors (odds ratio [OR], 2.672; 95% confidence interval [CI], 1.035 to 6.892), doctors who agreed that referring my patients to a HPC means I must give up on my patient (OR, 3.075; 95% CI, 1.324 to 7.127), and doctors who had no experience with HPC education (OR, 3.337; 95% CI, 1.600 to 7.125) were associated with higher expected effectiveness of PCT activities.

CONCLUSION

The PCT activities were expected to fill the doctor's perceived unmet HPC needs of terminal cancer patients and difficulties in communications.

Patients', family caregivers', and professionals' perspectives on quality of palliative care: a qualitative study

BACKGROUND

The quality of palliative care is the foremost preoccupation of clinicians, decision-makers, and managers as well as patients and families. Major input from healthcare professionals is required to develop indicators for the quality of palliative care, but the involvement of patients and families is also recognized as essential, even though this is rarely achieved in practice.

AIM

The objectives of this study were to identify (1) convergences and divergences in the points of view of different stakeholders (patients, families, healthcare professionals) relative to key elements of the quality of palliative care and (2) avenues for refining existing indicators of quality of palliative care.

DESIGN

Cross-sectional qualitative study.

SETTING/PARTICIPANTS

There were six settings: two hospital-based palliative care units, one hospice, and three other medical units where a mobile palliative care team intervene. Semi-structured interviews were conducted among 61 patients, families, healthcare professionals, and managers.

RESULTS

Four major dimensions of quality of care are deemed critical by patients, their families, and professionals: comprehensive support for the patients themselves, clinical management, involvement of families, and care for the imminently dying person and death. Differences exist between various stakeholders regarding perceptions of some dimensions of quality of care. Avenues for improving current quality of care indicators are identified.

CONCLUSION

Our study results can be used to refine or develop quality indicators that truly mirror the points of view of patients and their families and of healthcare professionals.