Managing risk during care transitions when approaching end of life: A qualitative study of patients' and health care professionals' decision making

What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review

BACKGROUND

As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?'

METHODS

The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period.

RESULTS

We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment.

CONCLUSIONS

This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.

Who Gets to Determine Whether Home Is "Unsafe" at the End of Life?

Background

At the end of life, some patients wish to be discharged directly home from the hospital, but health care teams may consider this unsafe, raising concerns for capacity and risk. However, defining risk is subjective and impacted by values, preferences, and clinical status. Accommodating patient preferences in discharge destinations can promote autonomy, dignity, and quality of life at the end of life.

Observations

We developed a risk assessment framework to help clinicians objectively identify risk factors and protective factors and develop a comprehensive discharge plan. We applied this framework to a veteran nearing the end of life and he was able to successfully return home from the hospital.

Conclusions

Approaching end-of-life discharges with a framework can inform discharge planning and lessen the risk of adverse events. Importantly, this framework can help clinicians communicate better and partner with patients and their loved ones in prioritizing patient values and preferences.

Qualitative longitudinal research in health research: a method study

Background

Qualitative longitudinal research (QLR) comprises qualitative studies, with repeated data collection, that focus on the temporality (e.g., time and change) of a phenomenon. The use of QLR is increasing in health research since many topics within health involve change (e.g., progressive illness, rehabilitation). A method study can provide an insightful understanding of the use, trends and variations within this approach. The aim of this study was to map how QLR articles within the existing health research literature are designed to capture aspects of time and/or change.

Methods

This method study used an adapted scoping review design. Articles were eligible if they were written in English, published between 2017 and 2019, and reported results from qualitative data collected at different time points/time waves with the same sample or in the same setting. Articles were identified using EBSCOhost. Two independent reviewers performed the screening, selection and charting.

Results

A total of 299 articles were included. There was great variation among the articles in the use of methodological traditions, type of data, length of data collection, and components of longitudinal data collection. However, the majority of articles represented large studies and were based on individual interview data. Approximately half of the articles self-identified as QLR studies or as following a QLR design, although slightly less than 20% of them included QLR method literature in their method sections.

Conclusions

QLR is often used in large complex studies. Some articles were thoroughly designed to capture time/change throughout the methodology, aim and data collection, while other articles included few elements of QLR. Longitudinal data collection includes several components, such as what entities are followed across time, the tempo of data collection, and to what extent the data collection is preplanned or adapted across time. Therefore, there are several practices and possibilities researchers should consider before starting a QLR project.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01732-4.

Implementation of eHealth to Support Assessment and Decision-making for Residents With Dementia in Long-term Care: Systematic Review

BACKGROUND

As dementia progresses, symptoms and concerns increase, causing considerable distress for the person and their caregiver. The integration of care between care homes and health care services is vital to meet increasing care needs and maintain quality of life. However, care home access to high-quality health care is inequitable. eHealth can facilitate this by supporting remote specialist input on care processes, such as clinical assessment and decision-making, and streamlining care on site. How to best implement eHealth in the care home setting is unclear.

OBJECTIVE

The aim of this review was to identify the key factors that influence the implementation of eHealth for people living with dementia in long-term care.

METHODS

A systematic search of Embase, PsycINFO, MEDLINE, and CINAHL was conducted to identify studies published between 2000 and 2020. Studies were eligible if they focused on eHealth interventions to improve treatment and care assessment or decision-making for residents with dementia in care homes. Data were thematically analyzed and deductively mapped onto the 6 constructs of the adapted Consolidated Framework for Implementation Research (CFIR). The results are presented as a narrative synthesis.

RESULTS

A total of 29 studies were included, focusing on a variety of eHealth interventions, including remote video consultations and clinical decision support tools. Key factors that influenced eHealth implementation were identified across all 6 constructs of the CFIR. Most concerned the inner setting construct on requirements for implementation in the care home, such as providing a conducive learning climate, engaged leadership, and sufficient training and resources. A total of 4 novel subconstructs were identified to inform the implementation requirements to meet resident needs and engage end users.

CONCLUSIONS

Implementing eHealth in care homes for people with dementia is multifactorial and complex, involving interaction between residents, staff, and organizations. It requires an emphasis on the needs of residents and the engagement of end users in the implementation process. A novel conceptual model of the key factors was developed and translated into 18 practical recommendations on the implementation of eHealth in long-term care to guide implementers or innovators in care homes. Successful implementation of eHealth is required to maximize uptake and drive improvements in integrated health and social care.

Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study

Objective

Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.

Method

Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.

Results

Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.

Significance of results

Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.

Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

BACKGROUND

Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions.

AIM

The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings.

DESIGN

A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662.

DATA SOURCES

We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes.

RESULTS

Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home.

CONCLUSION

This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

Factors related to satisfaction of cancer patients with transfer arrangements made by university hospitals at the end-of-life in Japan: a cross-sectional questionnaire survey of bereaved family members

PURPOSE

Cancer patients in university hospitals often face a difficult decision regarding transfer to other care settings at the end-of-life. Arrangements for a satisfying transfer are important for reducing the psychosocial impact of the transition, but few studies have evaluated this aspect. This study aimed to identify factors related to the satisfying arrangement of transfers to other care settings from university hospitals.

METHODS

A total of 400 bereaved family members of cancer patients in Japan participated in this cross-sectional web-based questionnaire survey. Statistical methods including decision tree analysis were conducted to identify factors significantly associated with satisfying transfer arrangements.

RESULTS

More than 60% of cancer patients were satisfied with the transfer arrangements made by university hospitals. Decision tree analysis revealed that the factor most significantly associated with satisfaction with transfer arrangements was "satisfaction with contents of the explanation about transfer." The following significant factors were also extracted: "timing of being informed of transfer," "presence of primary care physician," and "presence of trustworthy staff." "Satisfaction with overall care from university hospital staff" and "involvement of palliative care team" were identified as factors contributing to a high degree of satisfaction with transfer arrangements.

CONCLUSION

In order to make satisfying transfer arrangements from university hospitals for cancer patients at the end-of-life, healthcare professionals should provide satisfactory explanations about the transfer process in order to meet the information needs of patients. To be effective, healthcare professionals should initiate transfer arrangements prior to cancer treatment, while simultaneously building trusting relationships with patients.

A review of the literature on family decision-making at end of life precipitating hospital admission

Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: 'what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?' Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.

Staff perception of obstacles and facilitators when providing end of life care in critical care units of two teaching hospitals: A survey design

OBJECTIVE

To determine perceptions of Jordanian critical care staff about obstacles and facilitators to end-of-life care.

RESEARCH METHODOLOGY

The "National Survey of Critical Care Nurses' Perceptions of End-of-Life Care" was adapted and distributed to 143 critical care nurses (n = 110) and physicians (n = 33) in two Jordanian hospitals. Nurses and physicians completed items about perceived obstacles to end-of-life care. Nurses only completed items about facilitators to end-of-life care.

RESULTS

The overall response rate was 72.7% (n = 104/143). Seventy-six nurses (69.1%) and 28 physicians (84.5%) responded. Nurses and physicians agreed that the highest scoring obstacles were: 'family members who do not understand what life-saving measures mean' and the 'poor design of critical care units'. Other highly scoring obstacles related to clinicians' behaviours, characteristics and attitudes. Nurses perceived the highest scoring facilitator was 'family members who accepted that the patient was dying'.

CONCLUSION

There is a need to further explore the issues underlying perceptions about clinicians' behaviours, which were perceived to be key barriers to quality end-of-life care and to find acceptable solutions that fit with Islamic culture. It is the first time that the survey has been used to gather perceptions of doctors and nurses in a non-western culture.

Changing Focus: End-of-Life Care in a New York State Managed Long-Term Care Program

In the United States, managed long-term care programs offer a noninstitutional approach to meeting the needs of increasing numbers of frail elders. Providing services that support both quality of life and quality of dying poses unique challenges. Using a qualitative descriptive design, we explored these challenges from the perspectives of care providers. Themes were identified using qualitative content analysis techniques applied to transcripts of 33 semistructured interviews. Professionals comprising an interdisciplinary care team and home health aide direct care providers described cues by which they identified movement into the end-of-life phase, their understandings of how care changed, and their concerns and recommendations for improvement. When the changing care needs could be met, a "good death" ensued, but that was not always possible. Managed long-term care programs are called upon to develop the capacity to integrate the phase of dying into the full story of each life for which they care.