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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Sutherland M, Pyakurel A, Nolen AE, Stilos KK. Improving the Management of Terminal Delirium at the End of Life. Asia Pac J Oncol Nurs 2020; 7:389-395. [PMID: 33062836 PMCID: PMC7529019 DOI: 10.4103/apjon.apjon_29_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/04/2020] [Indexed: 11/05/2022] Open
Abstract
Objective: Terminal delirium is a distressing process that occurs in the dying phase, often misdiagnosed and undertreated. A hospital developed the “comfort measures order set” for dying patients receiving comfort care in the final 72 h of life. A chart review of patients experiencing terminal delirium revealed that the current medication option initially included in the order set was suboptimally effective and patients with terminal delirium were consistently undertreated. The purpose of this pilot study was to highlight an in-service intervention educating nurses on the management of terminal delirium at the end of life and to assess its effect on their knowledge of the management of patients with terminal delirium. Methods: A before-and-after survey design was used to assess the effect of the in-service training on nurses' knowledge of terminal delirium. Results: We describe the results from a small sample of nurses at a large urban tertiary care center in Canada. Of the twenty nurses who attended the in-services, 60% had cared for a patient with terminal delirium; however, 50% felt that their knowledge of the topic was inadequate. Despite no statistical significance between the pre- and posttest scores for both the oncology and the medicine unit nurses, all participants who completed posttest survey found the in-services useful. Conclusions: The findings from this study provide initial insights into the importance of in-service trainings to improve the end-of-life care and nursing practice. Future research will include expanding this pilot project with sufficient power to assess the significance of these types of interventions.
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Affiliation(s)
| | | | - Amy E Nolen
- Sunnybrook Health Sciences Centre, Toronto, Canada.,Palliative Care Consult Team, Toronto, Canada
| | - Kalliopi Kalli Stilos
- Sunnybrook Health Sciences Centre, Toronto, Canada.,Palliative Care Consult Team, Toronto, Canada.,Adjunct Clinical Faculty, University of Toronto's Lawrence Bloomberg Faculty of Nursing, Toronto, Canada
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3
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The value of the ethnographic approach to research issues in palliative care. Curr Opin Support Palliat Care 2020; 13:337-343. [PMID: 31689271 DOI: 10.1097/spc.0000000000000460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Qualitative research in the field of palliative care allows for a crucial study of the final stage of life from a social point of view and cultural perspective. This review evaluates the advantages and challenges of applying an ethnographic approach to palliative care research. RECENT FINDINGS Thirteen ethnographic articles on organization or quality of care, decision-making, delirium, death, and the process of dying, were reviewed. Most studies use interviews, participant observation, and field notes as their primary data collection techniques. In ethnographic research, cultural issues, relationships and interactions of a group, the meanings and perceptions of the participants, the communication process, and the use of language in a particular and natural context were analyzed. Data collection and information analysis took an average of 14 months in the included studies. SUMMARY The ethnographic method, applied with rigor, is valuable in the analysis of a real phenomenon if the particular context in which the study developed is well defined. With an ethnographic approach, researchers can uncover cultural nuances that evidence different realities.
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Waterfield K, Weiand D, Dewhurst F, Kiltie R, Pickard J, Karandikar U, MacCormick F, Vidrine J, Rowley G, Coulter P, Lee M, Frew K. A qualitative study of nursing staff experiences of delirium in the hospice setting. Int J Palliat Nurs 2019; 24:524-534. [PMID: 30457465 DOI: 10.12968/ijpn.2018.24.11.524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND: Delirium is a common condition occurring in 13-42% of people admitted to palliative care units and up to 88% of these patients are at the end of their lives. It is frequently unrecognised and distressing to all those affected-patients, families and health professionals. In addition, there is considerable uncertainty surrounding its trajectory and optimal management, both of which can be inconsistent. AIMS: This study aims to explore the experience of nursing staff who are caring for patients with delirium in the hospice environment and understand any potential barriers to its management. METHODS: Semistructured interviews using emotional touchpoints were conducted with 12 nurses and six healthcare assistants in three hospices in North East England. Data was analysed using interpretative phenomenological analysis. FINDINGS: The results highlighted gaps in knowledge and understanding in the management of delirium. The results demonstrated delirium had significant emotional effects, which were associated with uncertainty in managing the condition and the impact of this uncertainty on the relationship between staff and patients. CONCLUSION: This study highlights the emotional impact of caring for patients with delirium. Future work is needed to address the areas of uncertainty identified and ascertain how to best support nursing staff in these challenges.
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Affiliation(s)
- Kerry Waterfield
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Donna Weiand
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Felicity Dewhurst
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Rachel Kiltie
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jonathan Pickard
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Ulka Karandikar
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Fiona MacCormick
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Jen Vidrine
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Grace Rowley
- Specialty trainees, Palliative Medicine, Health Education North East, UK
| | - Paul Coulter
- Consultant, Palliative Medicine, Queen Elizabeth Hospital, Gateshead
| | - Mark Lee
- Consultant, Palliative Medicine, St Benedict's hospice, Sunderland
| | - Katie Frew
- Consultant, Palliative Medicine, Northumbria Healthcare NHS Foundation Trust
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle SE, Cumming A, Caplan GA, Chye R, Le B, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Brown L, Fazekas B, Cheah SL, Edwards L, Agar M. Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial. BMJ Open 2019; 9:e026177. [PMID: 30696686 PMCID: PMC6352777 DOI: 10.1136/bmjopen-2018-026177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies. TRIAL REGISTRATION NUMBER ACTRN12617001070325; Pre-results.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Beverly Noble
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meg Brassil
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Susan E Kurrle
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Health Service, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Brian Le
- Palliative and Supportive Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University, and the Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville TN USA, Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Palliative Care, Calvary Health Care Kogarah, Sydney, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Linda Brown
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Layla Edwards
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
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Logan J. Recognising and managing delirium in patients receiving palliative and end of life care. Nurs Stand 2018; 33:63-68. [PMID: 30255687 DOI: 10.7748/ns.2018.e10888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 06/08/2023]
Abstract
Delirium is the most common neuropsychiatric disorder in patients with palliative and end of life care needs; therefore, providing effective care for patients, and their families, is a clinical priority for nurses. Delirium is characterised by a fluctuating state that affects an individual's attention, orientation, thinking, perception, memory, psychomotor behaviour, emotions and sleep-wake cycle. Early recognition, assessment and management of delirium is essential, because this has the potential to relieve distress and improve the quality of life and death for patients. This article discusses the causes, effects, and signs and symptoms of delirium. It also outlines the non-pharmacological and pharmacological strategies that can be used to assess and manage patients with delirium at the end of life, alongside the support that should be provided to their families.
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Alftberg Å, Ahlström G, Nilsen P, Behm L, Sandgren A, Benzein E, Wallerstedt B, Rasmussen BH. Conversations about Death and Dying with Older People: An Ethnographic Study in Nursing Homes. Healthcare (Basel) 2018; 6:E63. [PMID: 29899220 PMCID: PMC6023469 DOI: 10.3390/healthcare6020063] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 02/07/2023] Open
Abstract
Nursing homes are often places where older persons “come to die.” Despite this, death and dying are seldom articulated or talked about. The aim of this study was to explore assistant nurses’ experiences of conversations about death and dying with nursing home residents. This study is part of an implementation project through a knowledge-based educational intervention based on palliative care principles. An ethnographic study design was applied in seven nursing homes, where eight assistant nurses were interviewed and followed in their daily assignments through participant observations. The assistant nurses stated that they had the knowledge and tools to conduct such conversations, even though they lacked the time and felt that emotional strain could be a hinder for conversations about death and dying. The assistant nurses used the strategies of distracting, comforting, and disregarding either when they perceived that residents’ reflections on death and dying were part of their illness and disease or when there was a lack of alignment between the residents’ contemplations and the concept of dying well. They indicated that ambivalence and ambiguity toward conversations about death and dying should be taken into consideration in future implementations of knowledge-based palliative care that take place in nursing homes after this project is finalized.
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Affiliation(s)
- Åsa Alftberg
- Department of Social Work, Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden.
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00 Lund, Sweden.
| | - Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83 Linköping, Sweden.
| | - Lina Behm
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00 Lund, Sweden.
| | - Anna Sandgren
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Eva Benzein
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Birgitta Wallerstedt
- Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, SE-351 95 Växjö, Sweden.
| | - Birgit H Rasmussen
- Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 157, SE-221 00 Lund, Sweden.
- The Institute for Palliative Care, Region Skane and Lund University, P.O. Box 157, SE-221 00 Lund, Sweden.
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Wright DK, Brajtman S, Macdonald ME. Relational ethics of delirium care: Findings from a hospice ethnography. Nurs Inq 2018; 25:e12234. [PMID: 29573054 DOI: 10.1111/nin.12234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2018] [Indexed: 01/27/2023]
Abstract
Delirium, a common syndrome in terminally ill people, presents specific challenges to a good death in end-of-life care. This paper examines the relational engagement between hospice nurses and their patients in a context of end-of-life delirium. Ethnographic fieldwork spanning 15 months was conducted at a freestanding residential hospice in eastern Canada. A shared value system was apparent within the nursing community of hospice; patients' comfort and dignity were deemed most at stake and therefore commanded nurses' primary attention. This overarching commitment to comfort and dignity shaped all of nursing practice in this hospice, including practices related to end-of-life delirium. The findings of this study elaborate the ways in which hospice nurses interpreted and responded to the discomfort of their patients in delirium, as well as the efforts they made to understand their patients' subjective experiences and to connect with them in supportive ways. In addition to what is already known about clinical assessment and treatment of delirium in palliative care settings, the findings of this study offer points of reflection for nurses anywhere who are contending with the relational challenges that delirium presents in end-of-life care.
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Affiliation(s)
- David Kenneth Wright
- School of Nursing, University of Ottawa, Ottawa, ON, Canada.,Nursing Palliative Care Research and Education Unit, University of Ottawa, Ottawa, ON, Canada
| | - Susan Brajtman
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mary Ellen Macdonald
- Division of Oral Health and Society, Faculty of Dentistry, McGill University, Montreal, QC, Canada
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Wright DK, Vanderspank-Wright B, Holmes D, Skinner E. Forensic nursing and the palliative approach to care: an empirical nursing ethics analysis. Int J Palliat Nurs 2017; 23:378-385. [PMID: 28854050 DOI: 10.12968/ijpn.2017.23.8.378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A movement is underway to promote a palliative approach to care in all contexts where people age and live with life-limiting conditions, including psychiatric settings. Forensic psychiatry nursing-a subfield of mental health nursing- focuses on individuals who are in conflict with the criminal justice system. We know little about the values of nurses working in forensic psychiatry, and how these values might influence a palliative approach to care for frail and aging patients. METHOD Interviews with four nurses working on one of two forensic units of a university-affiliated mental health hospital in an urban area of eastern Canada. FINDINGS Three specific values were found to guide forensic nurses in their care of aging patients that are commensurate with a palliative approach: hope, inclusivity, and quality of life. CONCLUSION When we started this project, we wondered whether the culture of forensic nursing practice was antithetical to the values of a palliative approach. Instead, we found several parallels between forensic nurses' moral identities and palliative philosophy. These findings have implications for how we think about the palliative approach in contexts not typically associated with palliative care, but in which patients will increasingly age and die.
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Affiliation(s)
- David Kenneth Wright
- Assistant Professor, University of Ottawa School of Nursing and Co-Director, Nursing Palliative Care Research and Education Unit, Canada
| | - Brandi Vanderspank-Wright
- Assistant Professor, University of Ottawa School of Nursing and Co-Director, Nursing Palliative Care Research and Education Unit, Canada
| | - Dave Holmes
- Full Professor, University of Ottawa School of Nursing and University Research Chair in Forensic Nursing, Canada
| | - Elise Skinner
- Graduate Student, University of Ottawa School of Nursing, Canada
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10
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Hosie A, Agar M, Lobb E, Davidson PM, Phillips J. Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis. Int J Nurs Stud 2017; 75:123-129. [PMID: 28783489 DOI: 10.1016/j.ijnurstu.2017.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 07/04/2017] [Accepted: 07/08/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Delirium is a serious acute neurocognitive condition frequently occurring for hospitalized patients, including those receiving care in specialist palliative care units. There are many delirium evidence-practice gaps in palliative care, including that the condition is under-recognized and challenging to assess. OBJECTIVES To report the meta-synthesis of a research project investigating delirium epidemiology, systems and nursing practice in palliative care units. METHODS The Delirium in Palliative Care (DePAC) project was a two-phase sequential transformative mixed methods design with knowledge translation as the theoretical framework. The project answered five different research questions about delirium epidemiology, systems of care and nursing practice in palliative care units. Data integration and metasynthesis occurred at project conclusion. RESULTS There was a moderate to high rate of delirium occurrence in palliative care unit populations; and palliative care nurses had unmet delirium knowledge needs and worked within systems and team processes that were inadequate for delirium recognition and assessment. The meta-inference of the DePAC project was that a widely-held but paradoxical view that palliative care and dying patients are different from the wider hospital population has separated them from the overall generation of delirium evidence, and contributed to the extent of practice deficiencies in palliative care units. CONCLUSION Improving palliative care nurses' capabilities to recognize and assess delirium will require action at the patient and family, nurse, team and system levels. A broader, hospital-wide perspective would accelerate implementation of evidence-based delirium care for people receiving palliative care, both in specialist units, and the wider hospital setting.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia.
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
| | - Elizabeth Lobb
- Calvary Health Care Sydney, Palliative Care Department, 91-111 Rocky Point Rd, Kogarah, NSW 2217, Australia
| | - Patricia M Davidson
- Johns Hopkins University, School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, United States
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney (UTS), Faculty of Health Building 10, Level 3, 235-253 Jones St, Ultimo, NSW 2007, Australia
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DeForest A, Blinderman CD. Persistent Delirium in Chronic Critical Illness as a Prodrome Syndrome before Death. J Palliat Med 2017; 20:569-572. [PMID: 28437207 DOI: 10.1089/jpm.2016.0415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Chronic critical illness (CCI) patients have poor functional outcomes, high risk of mortality, and significant sequelae, including delirium and cognitive dysfunction. The prognostic significance of persistent delirium in patients with CCI has not been well described. OBJECTIVE We report a case of a patient with CCI following major cardiac surgery who was hemodynamically stable following a long course in the cardiothoracic intensive care unit (CTICU), but had persistent and unremitting delirium. Despite both pharmacological and nonpharmacological approaches to improve his delirium, the patient ultimately continued to have symptoms of delirium and subsequently died in the CTICU. Efforts to reconsider the goals of care, given his family's understanding of his values, were met with resistance as his cardiothoracic surgeon believed that he had a reasonable chance of recovery since his organs were not in failure. This case description raises the question of whether we should consider persistent delirium as a prodrome syndrome before death in patients with CCI. DESIGN Study and analysis of a case of a patient with CCI following major cardiothoracic surgery who was hemodynamically stable with persistent delirium. CONCLUSIONS Further studies of the prevalence and outcomes of prolonged or persistent agitated delirium in patients with chronic critical illness are needed to provide prognostic information that can assist patients and families in receiving care that accords with their goals and values.
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Affiliation(s)
- Anna DeForest
- 1 College of Physicians and Surgeons, Columbia University , New York, New York
| | - Craig D Blinderman
- 2 Adult Palliative Care Service, Columbia University Medical Center and NewYork-Presbyterian Hospital , New York, New York
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12
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Hosie A, Agar M, Phillips J. Re-thinking our approach to care of the dying person with delirium: time for a new care paradigm. Int J Palliat Nurs 2016; 22:472-473. [DOI: 10.12968/ijpn.2016.22.10.472] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Annmarie Hosie
- Centre for Cardiovascular and Chronic Care Faculty of Health, University of Technology Sydney Sydney Australia
| | - Meera Agar
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jane Phillips
- Professor of Nursing (Palliative Care) and Director, Centre for Cardiovascular and Chronic Care Faculty of Health, University of Technology Sydney, Sydney, Australia
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