Initial perceptions of palliative care: An exploratory qualitative study of patients with advanced cancer and their family caregivers

Discourse Analysis in End-of-Life Communication: A Systematic Review

Discourse analysis (DA) has emerged as a valuable method for examining communication between participants in end-of-life (EOL) care. However, there remains a gap in synthesizing the findings of discourse analytic studies focused on communication within EOL care settings. The aim of this study was to synthesize DA studies in EOL care. A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (Prisma) guidelines. An electronic database of Web of Science (WOS), MEDLINE, PubMed, and Embase was performed. 14 peer-reviewed studies published in English before January 10 2024, were included. Thematic analysis identified three overarching themes: (1) caregivers' discursive stances on EOL care, (2) discursive practices of participants in shared decision-making conversations, and (3) discursive resources in talking illness trajectories. Findings suggest that DA has the potential to provide insights into understanding communication practices in EOL care and examining an individual's stance on issues about EOL care, thus informing clinical practice and improving patient-centered care.

Early palliative care perceptions by patients with cancer and primary caregivers: metaphorical language

OBJECTIVE

This article reports on the results of an analysis of metaphorical language used by patients diagnosed with advanced cancer and their caregivers receiving early palliative care (EPC).

METHODS

Data were collected through a pen-and-paper questionnaire on respondents' perceptions of the disease, its treatment and their idea of death, before and after receiving EPC. The data were analysed by identifying all metaphorical uses of language, following the 'metaphor identification procedure' proposed by the Praggjelaz Group.

RESULTS

Metaphors were used from a variety of semantic fields. EPC was described using spiritual terms, to indicate that this approach was instrumental in 'restoring life', 'producing hope' and making patients feel 'accompanied'. The most recurrent metaphors were those referring to light and salvation; spatial metaphors were used to describe the treatment and the hospital as a 'safe haven' and 'an oasis of peace'. Patients and caregivers were overall consistent in the aforementioned ways of referring to illness and treatment; caregivers were more likely than patients to use war metaphors, although their use overall was rare.

CONCLUSIONS

Our results suggest that EPC is perceived positively by patients and their caregivers and provide insights regarding the manner in which EPC could be presented to patients, caregivers and the public.

The General Public and Young Adults' Knowledge and Perception of Palliative Care: A Systematic Review

Background: As a result of demographic change, chronic and oncological diseases are gaining importance in the context of public health. Palliative care plays a crucial role in maintaining the quality of life of those affected. International guidelines demand access to palliative care not only for the elderly but also for younger people who face severe illnesses. It can be assumed that palliative care will become increasingly important for them. In order to develop public health strategies which are able to promote palliative care, it is important to assess the knowledge of, and attitude towards, palliative care as found among members of the general public and its specific target groups. In particular, little is known about young adults' knowledge and perceptions of palliative care. Objectives and design: This work aimed to assess the understanding and viewpoints regarding palliative care among the general population and among young adults aged 18 to 24. We therefore conducted a systematic review, which, for this target population, could be seen as a novel approach. Methods: Exclusion and inclusion criteria were developed using the PICOS process. Literature was researched within MEDLINE (via PubMed), Google Scholar and Web of Science. A search string was developed and refined for all three databases. Grey literature was included. Duplicates were excluded using Mendeley. The literature was independently screened by two researchers. Narrative synthesis was used to answer the main research question. Results: For the general public, palliative care is still associated with death and dying and comforting sick people towards the end of their lives. Multiple social determinants are linked to better knowledge of palliative care: higher education, higher income, female gender, having relatives that received palliative care, and permanent employment. The population's knowledge of palliative care structures increases, the longer such structures have been established within a country. Young adults are familiar with the term palliative care, yet their understanding lacks nuance. They associate palliative care with death and dying and perceive palliative care to be a medical discipline primarily for the elderly. Nevertheless, young adults demand participation within the planning of interventions to destigmatize palliative care. Conclusions: The general public still lacks a detailed understanding of palliative care. Palliative care faces stigma at multiple levels, which creates barriers for those who set out to implement it. However, addressing young adults as a crucial peer group can help break down barriers and promote access to palliative care.

Perceptions of Palliative Care: Demographics and Health Status Among the General Population in Florida and the United States

BACKGROUND

Palliative care (PC) helps maintain quality of life for seriously ill patients, yet, many Americans lack knowledge of PC.

AIM

To explore the relationships between knowledge of PC of individuals living in north-central Florida and throughout the United States.

DESIGN

This cross-sectional survey with three sampling approaches, one was a community-engaged sample and two were panel respondent samples. Respondents and setting: Respondents of the Florida sample (n1 = 329) and the community-engaged sample (n2 = 100), were representative of the 23 Florida county general population. Respondents of the national sample (n = 1800) were adult members of a panel owned by a cloud-based survey platform.

RESULTS

Young adults compared with adults (OR 1.62, 95% CI 1.14-2.28, P .007), middle-adults (OR 2.47, 95% CI 1.58-3.92, P < .001) and older-adults (OR 3.75, 95% CI 2.50-5.67, P < .001) were less likely to agree that the goal of PC is to help friends and family cope with a patient's illness, and that the goal of PC is to manage pain and other physical symptoms compared with adults (OR 1.67, 95% CI 1.20-2.30, P .002) middle-adults (OR 2.58, 95% CI 1.71-3.95, P < .001) and older-adults (OR 7.19, 95% CI 4.68-11.2, P < .001). Participants with greater rural identity (OR 1.39, 95% CI 1.31-1.48, P < .001) were more likely to agree that accepting PC means giving up.

CONCLUSIONS

Increased knowledge of PC might be influenced through targeting educational interventions and educating the general population through social media use.

Introducing palliative care in advanced cancer: a systematic review

BACKGROUND

Negative perceptions about palliative care (PC), held by patients with cancer and their families, are a barrier to early referral and the associated benefits. This review examines the approaches that support the task of introducing PC to patients and families and describes any evaluations of these approaches.

METHODS

A systematic review with a systematic search informed by the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines was performed on the online databases MEDLINE, PsychInfo and CINAHL from May 2022 to July 2022. Identified studies were screened by title and abstract, and included if they were empirical studies and described an approach that supported the introduction of PC services for adult patients. A narrative-synthesis approach was used to extract and present the findings.

RESULTS

Searches yielded 1193 unique manuscripts, which, following title and abstract screening, were reduced to 31 papers subject to full-text review, with a final 12 studies meeting eligibility criteria. A diverse range of included studies described approaches used to introduce palliative care, which may be broadly summarised by four categories: education, clinical communication, building trust and rapport and integrative system approaches.

CONCLUSION

While educational approaches were helpful, they were less likely to change behaviours, with focused communication tasks also necessary to facilitate PC introduction. An established relationship and trust between patient and clinician were foundational to effective PC discussions. A framework to assist clinicians in this task is likely to be multidimensional in nature, although more quantitative research is necessary to establish the most effective methods and how they may be incorporated into clinical practice.

Managing understandings of palliative care as more than care immediately before death: Evidence from observational analysis of consultations

BACKGROUND

Evidence suggests that public, and some professional, understandings of palliative care are limited to care provided immediately before death, which contrasts palliative care's scope as care provided across a range of illness stages.

OBJECTIVE

To examine how clinicians manage patients' understandings of palliative care during initial consultations.

DESIGN

Initial palliative care consultations were video-recorded and analysed using conversation analytic methods.

SETTING/PARTICIPANTS

Consultations were recorded in a specialist palliative care outpatient unit within an Australian public hospital. Participants included 20 newly referred patients and their families, and three palliative care clinicians.

RESULTS

During initial consultations, it was observed that specialist palliative care clinicians frequently managed the possibility that patients may understand palliative care as limited to care provided immediately before death. Clinicians used recurrent practices that seemed designed to pre-empt and contradict patients' possible narrow understandings. When discussing the palliative care inpatient unit, clinicians recurrently explained inpatient care could include active treatment and referred to the possibility of being discharged. These practices contradict possible understandings that future admission to the inpatient unit would be solely for care immediately before death.

DISCUSSION

The findings demonstrate that palliative care clinicians are aware of possible narrow understandings of their discipline among members of the public. The practices identified show how clinicians pre-emptively manage these understandings to patients newly referred to palliative care.

CONCLUSIONS

These findings highlight scope for greater partnership with teams referring patients to palliative care, to assist patients in understanding the range of reasons for their referral.

PATIENT OR PUBLIC CONTRIBUTION

The observational method of conversation analysis provides direct insight into matters that are relevant for patients, as raised in their consultations with clinicians. This direct evidence enables analysis of their lived experience, as it occurs, and grounds analysis in observable details of participants' conduct, rather than interpretations of subjective experiences. The patients' contributions, therefore, were to allow observation into their initial palliative care consultations.

Reach of Palliative Care for Parkinson Disease: Results From a Large National Survey of Patients and Care Partners

Background and Objectives

People with Parkinson disease (PWP) and their care partners have high palliative care needs resulting from disabling motor and nonmotor symptoms. There is growing support for palliative care (PC) approaches to Parkinson disease. However, little is known regarding the extent to which the palliative needs of PWP and care partners are currently being met. This study's primary objective is to describe PWP's and care partners' perceptions of the extent to which their PC needs are being met. Secondary objectives are to describe their perceptions of the quality of clinical communication and their knowledge of PC.

Methods

PWPs and care partners (n = 12,995) who had consented to receiving surveys from the Parkinson's Foundation were emailed an electronic survey. PC was operationalized as comprising 5 key components: systematic assessment and management of (1) nonmotor symptoms, (2) PWPs' emotional and spiritual needs, (3) care partners' needs, (4) the completion of annual advance care planning, and (5) timely referrals to specialist palliative care and hospice when appropriate.

Results

A total 1,882 individuals (1,266 PWP and 616 care partners) responded to the survey (response rate 14.5%). Few PWP (22%) reported that their neurologists never asked regarding bothersome nonmotor symptoms or did so or only if they brought it up. Fifty percent of PWP reported that pain as a specific nonmotor symptom was never managed or managed only if they brought it up. Similarly, PWPs' emotional and spiritual needs (55%), care partners' well-being (57%), and completion of advance care planning documentation (79%) were never addressed or only addressed if PWP brought it up. The quality of clinical communication was generally rated as open and honest (64% PWP). Fewer PWP (30%) reported that doctors helped them deal with the uncertainties of Parkinson disease. Most PWP (85%) reported being knowledgeable regarding PC, and 68% reported that the goal of PC was to help friends and family cope with the illness.

Discussion

Although some elements of PC are currently being addressed in routine care for PWP, there are many gaps and opportunities for improvement. These data may facilitate focused attention and development of resources to improve the quality and availability of PC for Parkinson disease.

Changing patterns of care for pancreas cancer in Victoria: the 2022 Pancreas Tumour Summit

BACKGROUND

The Victorian Government convened the second Pancreas Cancer Summit in 2021 to identify unwarranted variation in care 2016-2019, and to assess trends compared with the first Summit 2017 (reporting 2011-2015). State-wide administrative data were assessed at population level in alignment with optimal care pathways across all stages of the cancer care continuum.

METHODS

Data linkage performed by Centre for Victorian Data Linkage combined data from Victorian Cancer Registry with other administrative data sets including Victorian Admitted Episodes Dataset, Victorian Radiotherapy Minimum Data Set, Victorian Emergency Minimum Dataset and Victorian Death Index. A Cancer Service Performance Indicator audit was carried out providing an in-depth analysis of identified areas of interest.

RESULTS

Of 3138 Victorians diagnosed with pancreas ductal adenocarcinoma 2016-2019, 63% were metastatic at diagnosis. One-year survival increased between time periods, from 29.7% overall 2011-2015 (59.1% for non-metastatic, and 15.1% metastatic) to 32.5% overall 2016-2019 (P < 0.001), 61.2% non-metastatic (P = 0.008), 15.7% metastatic (P = NS). A higher proportion of non-metastatic patients progressed to surgery (35% vs. 31%, P = 0.020), and more received neoadjuvant therapy (16% vs. 4%, P < 0.001). Postoperative mortality following pancreatectomy at 30 and 90 days remained low at 2%. Utilization of 5FU-based chemotherapy regimens increased between 2016 and 2020. Multidisciplinary Meeting (MDM) presentation was still below the 85% target (74%) as was supportive care screening (39%, target 80%).

CONCLUSIONS

Surgical outcomes remain world-class and there has been an appropriate shift in chemotherapy administration towards neoadjuvant timing with increasing use of 5FU-based regimens. MDM presentation rates, supportive care and overall care coordination remain areas of deficiency.

Translation and psychometric validation of the Persian version of palliative care attitudes scale in cancer patients

INTRODUCTION

To improve cancer patients' quality of life, palliative care is necessary. The growth of palliative care, along with the assistance of the government and the collaboration of specialists, also relies on the knowledge and attitude of people. In Iran, there is no tool available to gauge patient attitudes about palliative treatment. The Persian version of the Palliative Care Attitude Scale (PCAS-9) was translated and psychometrically validated in this research among cancer patients.

METHODS

This methodological study was conducted in two stages: translation stage and psychometric validation stage. The method of translation was based on that proposed by Polit and Yang. Utilizing a qualitative approach, the scale's face and content validity were investigated. 162 cancer patients who required palliative care based on expert diagnosis participated in the confirmatory factor analysis to establish construct validity. Stability and internal consistency provided evidence of reliability. The data was examined using SPSS18 and AMOS.

RESULTS

The "Palliative Care Attitudes Scale" translated well across cultures. Validity on both the face and the content was acceptable. Confirmatory factor analysis (CFA) revealed a good fit for the original three-factor structure. The intra-class correlation coefficient (ICC) was equal to 0.89, while the internal consistency (Cronbach's alpha) reliability of the whole scale was equal to 0.77.

CONCLUSIONS

Persian version of the "Palliative Care Attitudes Scale" was acceptable and adequate in cancer patients. Using this tool makes it easier to assess how patients feel about receiving palliative care and how well training sessions are working to change patients' views.

Educational innovation as a communication strategy in palliative care: A study protocol and preliminary results

INTRODUCTION

Society associates palliative care with "death" or "end of life", which cause them fear and anxiety. In Spain, the media worsens the misunderstanding by depicting a wrong picture of palliative care. Educational innovation for university students may serve as an alternative communication strategy. Care and Society is a university course designed by and for students from non-health degrees to help disseminate the palliative care message. The first year of the Teach-Inn Pal project aims to evaluate the effects of the course and to identify areas of improvement.

OBJECTIVE

To present an evaluation to determine if the course can work as a campaign to refocus the public opinion on palliative care and share the preliminary results of the pilot study.

METHODOLOGY

A prospective Participatory Action Research study. University students enrolled in the course (n = 29) are invited to test and redesign the palliative care message. Knowledge and empathy will be measured throughout the learning process. Afterwards, qualitative, thematic, inductive analysis of the course material will be carried out. This study is registered on the ISRCTN Registry under the name "Can a university course help communicate palliative care?" (Registration number: ISRCTN10236642).

DISCUSSION

This study is part of a doctoral thesis. Education is used as a creative outlet, allowing rapid testing of multiple tools to create ambassadors of palliative care that may reframe the public opinion.

CONCLUSION

The understanding of students about palliative care changed, the overall impression of the experience was positive, and students were also able to explain palliative care to people with little or no experience in the topic. However, to determine if they became ambassadors the results of the mid-term assessment are required.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team

Background

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care.

Aim

This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task.

Methods

An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care.

Implications

This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review

Purpose

Early referral of patients with stage IV non-small cell lung cancer (NSCLC) to outpatient palliative care has been shown to increase survival and reduce unnecessary healthcare resource utilization. We aimed to determine outpatient palliative care referral rate and subsequent resource utilization in patients with stage IV NSCLC in a multistate, community-based hospital network and identify rates and reasons for admissions within a local healthcare system of Washington State.

Methods

A retrospective chart review of a multistate hospital network and a local healthcare system. Patients were identified using ICD billing codes. In the multistate network, 2844 patients diagnosed with stage IV NSCLC between January 1, 2013, and March 1, 2018, were reviewed. In the state healthcare system, 283 patients between August 2014 and June 2017 were reviewed.

Results

Referral for outpatient palliative care was low: 8% (217/2844) in the multistate network and 11% (32/283) in the local healthcare system. Early outpatient palliative care (6%, 10/156) was associated with a lower proportion of patients admitted into the intensive care unit in the last 30 days of life compared to no outpatient palliative care (15%, 399/2627; p = 0.003). Outpatient palliative care referral was associated with improved overall survival in Kaplan Meier survival analysis. Within the local system, 51% (104/204) of admissions could have been managed in outpatient setting, and of the patients admitted in the last 30 days of life, 59% (87/147) experienced in-hospital deaths.

Conclusion

We identified underutilization of outpatient palliative care services within stage IV NSCLC patients. Many patients with NSCLC experience hospitalization the last month of life and in-hospital death.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07364-0.

Palliative care facilitates the preparedness of caregivers for thoracic cancer patients

OBJECTIVE

Palliative care improves outcomes for patients with thoracic cancer; however, limited evidence exists for the benefits of this approach for caregivers. This study aimed to advance understanding of the experiences of palliative care described by bereaved caregivers.

METHODS

Fifteen adult caregivers completed semi-structured interviews following prior participation in a randomised controlled trial of early referral to palliative care versus discretionary referral to palliative care. Interviews explored caregiver experiences of palliative care delivery. Interview transcripts were thematically analysed.

RESULTS

Four related themes about the experiences of palliative care were identified, each of which required sufficient time between palliative care first contact and death: 'relationship building'; 'clear communication and information'; 'access to practical support'; and 'access to psychosocial support'. The core category underpinning these themes was palliative care facilitates caregiver preparedness. Caregivers noted that palliative care played a critical role in preparing them for the future and described a sense of practical and emotional 'relief' associated with the support services made available to them.

CONCLUSION

Our findings emphasise that palliative care can have a positive impact on caregivers' preparedness for providing the care needed by thoracic cancer patients and that this can improve the experiences of both caregivers and patients.

Delivery and outcomes of end-of-life care in the Australian context: Experiences and reflections of general practitioners

Previous research on general practitioners' (GPs') involvement in end-of-life care has largely focused on a specific aspect of care or has provided broad overviews that failed to capture individual variations in patient management. This qualitative study aimed to explore Australian GPs' feedback and reflections on the individual-level care provided for patients in their last year of life. The findings of the study were drawn from a nation-wide survey of GPs' experiences in end-of-life care. We analysed responses from 63 GPs for 267 of the 272 reported deaths. Factors influencing delivery of optimal end-of-life care reported by GPs were categorised into four groups: patient-related factors, carer-related factors, interactions between GPs and patients/carer-related factors and broader health system issues. Each group included both barriers and facilitators. Our study highlighted importance of the emotional dimensions of therapeutic relationships with patients and their family, availability and capacity of family support and smooth communication and continuity of care between GPs and hospitals in delivery of optimal end-of-life care. Lack of these facilitators, misconceptions of palliative care and conflicts on implementing care plans among patients and their family tended to impede delivery of such care. On the basis of our findings in the present study and previous literature, we conclude that improved end-of-life care in general practice requires comprehensive approaches to supporting both the GP and family to provide care in patients' preferred place, such as enhanced palliative care training and improved availability of external support for GPs, higher levels of hospital-based services reaching into community settings and broader community-based resources for families beyond simply the healthcare system.

The involvement of palliative care with neurology – a comparison of UK, Switzerland and Italy

OBJECTIVES

To ascertain the involvement of palliative care with neurology services in the care of people with amyotrophic lateral sclerosis (ALS) in the United Kingdom, Italy and Switzerland, in particular the collaboration with and referral from neurology, the involvement in multidisciplinary team care and in the respiratory support of ALS patients.

METHODS

In 2019, two online surveys were undertaken of palliative care specialists, using specialist groups of the European Academy of Neurology, European Association of Palliative Care and the Association of Palliative Medicine for Great Britain and Ireland.

RESULTS

The respondents were specialist palliative care professionals, predominantly senior doctors, involved in the care of people with ALS. As the numbers of respondents from many countries were in single figures the analysis was restricted to the United Kingdom, Italy and Switzerland. The time of involvement varied, with early involvement commonest in the UK. Barriers to referral included neurologists not referring and financial issues, particularly in Switzerland. The reluctance of patients and families to see palliative care services was reported as less than 20% in all countries. Respondents were often involved in the care of people receiving noninvasive ventilation (NIV), in all countries. and with tracheostomy ventilation (TV), particularly in Italy.

CONCLUSIONS

Palliative care services are often involved in the care of people with ALS, but the extent and timing of involvement varies. The use of clinical guidelines and education on palliative care for neurology services may encourage collaboration, for the benefit of people with ALS and their families.

Is the use of palliative care services increasing? A comparison of current versus historical palliative care access using health service datasets for patients with cancer

BACKGROUND

Mature evidence exists supporting the integration of palliative care in cancer care, but translation of evidence into practice is less well understood.

AIM

We sought to understand current access to palliative care and its timing for people with cancer and to compare practices over time.

DESIGN

We conducted a retrospective population cohort study using routinely collected administrative health data sets in Victoria, Australia.

SETTING/PARTICIPANTS

All adult cancer decedents in 2018 were identified and clinical, demographic, palliative care access and quality of end of life care indices collected.Comparisons between a historic cohort of lung, breast and prostate cancer patients who died between the years 2005 and 2009 and those with these diagnoses in the current cohort.

RESULTS

In 2018 there were 10,245 Victorian decedents with a cancer-coded cause of death, of these 3689 had lung, prostate or breast cancer. In 2018, access to palliative care increased (66% vs 54%) and greater numbers accessed palliative care more than 3 months before death (18% vs 10%) than in 2005-2009. Indices of end of life quality improved across most domains. However the median time between first palliative care and death was shorter in 2018 (22 vs 25 days) and more people first accessed palliative care in the hospitalisation during which they died (43% vs 33%).

CONCLUSION

Despite established benefits of early palliative care, the important task of translation of this evidence into practice remains.

The feasibility of triggers for the integration of Standardised, Early Palliative (STEP) Care in advanced cancer: A phase II trial

Background

While multiple clinical trials have demonstrated benefits of early palliative care for people with cancer, access to these services is frequently very late if at all. Establishing evidence-based, disease-specific ‘triggers’ or times for the routine integration of early palliative care may address this evidence-practice gap.

Aim

To test the feasibility of using defined triggers for the integration of standardised, early palliative (STEP) care across three advanced cancers.

Method

Phase II, multi-site, open-label, parallel-arm, randomised trial of usual best practice cancer care +/- STEP Care conducted in four metropolitan tertiary cancer services in Melbourne, Australia in patients with advanced breast, prostate and brain cancer. The primary outcome was the feasibility of using triggers for times of integration of STEP Care, defined as enrolment of at least 30 patients per cancer in 24 months. Triggers were based on hospital admission with metastatic disease (for breast and prostate cancer), or development of disease recurrence (for brain tumour cohort). A mixed method study design was employed to understand issues of feasibility and acceptability underpinning trigger points.

Results

The triggers underpinning times for the integration of STEP care were shown to be feasible for brain but not breast or prostate cancers, with enrolment of 49, 6 and 10 patients across the three disease groups respectively. The varied feasibility across these cancer groups suggested some important characteristics of triggers which may aid their utility in future work.

Conclusions

Achieving the implementation of early palliative care as a standardized component of quality care for all oncology patients will require further attention to defining triggers. Triggers which are 1) linked to objective points within the illness course (not dependent on recognition by individual clinicians), 2) Identifiable and visible (heralded through established service-level activities) and 3) Not reliant upon additional screening measures may enhance their feasibility.

Factors That Determine the Experience of Transition to an Inpatient Palliative Care Unit for Patients and Caregivers: A Qualitative Study

Objective: Transitions in care settings near the end of life can present challenges to patients and families, especially when there are also adjustments in level of care and illness trajectory. In this study, we explored what factors influenced how patients and family caregivers experienced a transition to an inpatient Palliative Care Unit (PCU). Methods: This qualitative study was conducted at a PCU in Toronto, Canada. Semi-structured interviews were held with 29 participants (14 patients and 15 family caregivers) during their time on the PCU. Data was analyzed through an iterative process of constant comparison to generate themes. The recruitment process continued to the point of thematic saturation. Results: Five themes were identified that represented the participants’ experiences in transitioning to the PCU: Being prepared, Feeling supported, Coming to terms with end of life issues, Dealing with uncertainty, and Continuity of care. Conclusions: Our findings highlight the need for clear and iterative communication with patients and family caregivers during the transition to a PCU. Identification and consideration of the common themes involved in the experience of transfer to PCU can help guide future practice and improve the experience of patients and families during transitions at the end of life.

Factors Influencing Public Awareness of and Attitudes Toward Palliative Care: A Cross-Sectional Analysis of the 2018 HINTS Data

Background

The global burden of serious health-related suffering requiring palliative care has been projected to grow significantly by 2060, which indicates the imminent need for integrating palliative care into health systems globally. Moreover, research evidence has been accumulating in support of the earlier adoption of palliative care into the treatment course of serious life-threatening illnesses. However, barriers to earlier access to palliative care still remain, which might be attributable to the global lack of awareness of palliative care and the prevalence of negative perceptions and attitudes. To address this, further investigation of the influencing factors of public perceptions of palliative care is imperative to help inform and develop effective targeted public health campaigns and education messages aimed at improving views of palliative care and thereby early access.

Methods

We used data from the Health Information National Trends Survey (HINTS), a nationally representative cross-sectional survey routinely administrated by the National Cancer Institute from the United States. Specifically, we analyzed the latest palliative care data from HINTS 5 Cycle 2 data set. Sociodemographic characteristics, individual factors such as self-perceived health status, and interpersonal factors such as relationship quality were examined as predictors of public awareness of and attitudes toward palliative care. Survey data were analyzed using SPSS 26 with multiple hierarchical regression tests.

Results

Results showed that people's quality of interpersonal relationships was a significant influencing factor of their awareness of and attitudes toward palliative care. Moreover, cancer diagnosis history and perceived healthcare quality were found to jointly affect their awareness of palliative care; perceived health status and patient centeredness interacted to influence their awareness of and attitudes toward palliative care. Finally, female, non-white, and poorer people were more aware of palliative care, while female and more educated people had more favorable attitudes.

Conclusions

The quality of social relationships emerges as a significant predictor of people's awareness of and attitude toward palliative care, as treatment options and decisions of serious life-threatening illnesses often involve the patients' family. The results hold strong implications for public health campaigns and education messages aiming at changing people's views of palliative care, which ultimately improve end-of-life outcomes.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences

OBJECTIVE

To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form.

DESIGN

Semi-structured interviews following a conversation about preferences for life-sustaining treatment.

SETTING

Danish hospitals, nursing homes, and general practitioners' clinics.

SUBJECTS

Patients and physicians.

MAIN OUTCOME MEASURES

Qualitative analyses of interview data.

FINDINGS

After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy.

CONCLUSION

Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

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

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

Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention

CONTEXT

Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care.

OBJECTIVES

To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy.

METHODS

The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes.

RESULTS

Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001).

CONCLUSIONS

This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.

Palliative care for patients around the time of haematopoietic stem cell transplant: a qualitative study of patients' perceptions and experiences of unmet need and attitudes towards palliative care involvement

BACKGROUND

Haemato-oncology patients are likely to be referred later to palliative care than patients with solid tumours, despite experiencing similar symptom burden. Patients prior to stem cell transplant may benefit from symptom control, advance care planning and shared decision-making, and previous studies have demonstrated feasibility and benefit of such a service. However, the views of patients are not yet established, and are vital to ensure acceptability of the service.

AIMS

To identify areas where a palliative care team may help to support patients being considered for a stem cell transplant, and to explore the attitudes and perceptions of patients towards palliative care at this time.

DESIGN

A qualitative study including interviews (N = 12) and a focus group (N = 4) for patients pre- and post-transplant, using a semi-structured format via telephone, online video-conferencing and face-to-face discussions. Recordings were transcribed and analysed using thematic analysis.

SETTING

A tertiary cancer centre in the UK.

FINDINGS

Themes identified were the following: Identified needs, Information and decision-making, Importance of relationships, Changing perceptions of what palliative care means, and The future. Patients associate palliative care with terminal care due to indirect experiences. Patients were open to palliative care once its purpose was explained and described emotional and physical needs relevant to early palliative care.

CONCLUSIONS

The involvement of early palliative care alongside haematology treatment prior to stem cell transplant may improve quality of life for patients and facilitate shared decision-making at a crucial stage of treatment. Early palliative care should be offered alongside haematology care around the time of stem cell transplant, with information provided to patients regarding its role.

Patient awareness of palliative care: systematic review

BACKGROUND

One of the barriers to the integration of palliative care within the process of patient care and treatment is the lack of awareness of patients about palliative care. In order to develop efficient resources to improve patient awareness, comprehensive information is required to determine the specific aspects of palliative care where a paucity of evidence on patient awareness exists. This review aims to synthesise evidence from previous studies in order to provide a comprehensive information set about the current state of patient awareness of palliative care.

METHODS

In this systematic literature review, PubMed, Scopus, Web of Science, ProQuest, Magiran, Scientific Information Database(SID) and Islamic Science Citation (ISC) were searched to identify articles published between 2000 and 2021 that considered patients' awareness of palliative care.

RESULTS

Of the 5347 articles found, 22 studies were retained after quality evaluation; three full-text articles were excluded. Nineteen articles are included in this review. More than half of the patients did not have any information about palliative care or hospice care. Some patients accurately defined hospice care and palliative care; other patients had misunderstandings about palliative care. Patients had limited information about pastoral care, social care and bereavement care. Patients' awareness about individuals or centres providing palliative care or hospice care was limited. Video presentation and distribution of information at the community level indicated that this method would be beneficial in increasing the awareness.

CONCLUSION

The review points to the need for patient education programmes and interventional studies to increase patients' awareness.

Palliative and End-of-Life Care Service Models: To What Extent Are Consumer Perspectives Considered?

This article presents evidence found in a search of national and international literature for patient preferences concerning settings in which to receive palliative care and the appropriateness of different models of palliative care. The purpose was to inform end-of-life care policy and service development of the Western Australian Department of Health through a rapid review of the literature. It was found that consumer experience of palliative care is investigated poorly, and consumer contribution to service and policy design is limited and selective. Most patients experience a mix of settings during their illness, and evidence found by the review has more to do with qualities and values that will contribute to good end-of-life care in any location. Models of care do not make systematic use of the consumer data that are available to them, although an increasingly common theme is the need for integration of the various sources of care supporting dying people. It is equally clear that most integration models limit their attention to end-of-life care provided by health services. Transitions between settings merit further attention. We argue that models of care should take account of consumer experience not by incorporating generalised evidence but by co-creating services with local communities using a public health approach.

Negative media portrayal of palliative care: a content analysis of print media prior to the passage of Voluntary Assisted Dying legislation in Victoria

Key misunderstandings of palliative care exist in the community, with media being reported as a key source underpinning knowledge. This retrospective media analysis of consecutive articles sought to examine the portrayal of palliative care in the Australian print media, focussing on the 2 years (2016-2018) coverage preceding the Voluntary Assisted Dying legislation in Victoria, Australia. Summative content analyses revealed coverage of palliative care was frequently (74%) in the context of a discussion of euthanasia. Only small numbers of articles described the activities of palliative care, and even fewer its potential beneficial impact, while a quarter (26%) described palliative care was inadequate to relieve suffering. These findings suggest that current coverage of palliative care in the media may contribute to negative public views and misconceptions. An opportunity exists to enhance media coverage, and in turn, improve the public understanding of care in serious illness.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preferences for end-of-life care settings among the healthy population in Israel—Related socio-demographic variables

Objective

Preferences for end-of-life (EoL) care settings is of considerable interest for developing public health policy and EoL care strategies. Culture, the cause of illness, and background characteristics may impact preferences. The present study aimed to explore preferences for EoL care settings: homes, hospitals, and inpatient hospice units among the general healthy population in Israel. Possible associations between the setting preferences and socio-demographic characteristics were also examined.

Method

A cross-sectional survey was conducted among 311 healthy adults who were recruited through a representative internet panel of the Israeli population using the Israeli census sampling method. The sex ratio was almost 1:1 with 158 women (50.8%) and 153 men (49.2%). All participants completed self-report measures using an online survey system. The questionnaires assessed sociodemographics and preferences for EoL care settings.

Results

This survey revealed that 52.1% of the participants expressed preference for being cared for at home rather than in an inpatient hospice unit, 40.8% expressed being cared for at home rather than in a hospital, while 36.7% had no preference regarding being cared for in hospital or in a hospice unit. Among the socio-demographic variables, only age and gender were found to be significantly associated with preferences for EoL care settings.

Significance of results

The present study highlights the need to be cautious when regarding home as the preferred EoL care setting, as some individuals declared that they would prefer EoL hospice/hospital care. Age and gender should be considered when discussing and tailoring strategies regarding EoL preferences.

Care plus study: a multi-site implementation of early palliative care in routine practice to improve health outcomes and reduce hospital admissions for people with advanced cancer: a study protocol

Background

Current international consensus is that ‘early’ referral to palliative care services improves cancer patient and family carer outcomes. In practice, however, these referrals are not routine. An approach which directly addresses identified barriers to early integration of palliative care is required. This protocol details a trial of a standardized model of early palliative care (Care Plus) introduced at key defined, disease-specific times or transition points in the illness for people with cancer. Introduced as a ‘whole of system’ practice change for identified advanced cancers, the key outcomes of interest are population health service use change.

The aims of the study are to examine the effect of Care Plus implementation on (1) acute hospitalisation days in the last 3 months of life; (2) timeliness of access to palliative care; (3) quality and (4) costs of end of life care; and (5) the acceptability of services for people with advanced cancer.

Methods

Multi-site stepped wedge implementation trial testing usual care (control) versus Care Plus (practice change). The design stipulates ‘control’ periods when usual care is observed, and the process of implementing Care Plus which includes phases of planning, engagement, practice change and evaluation. During the practice change phase, all patients with targeted advanced cancers reaching the transition point will, by default, receive Care Plus.

Health service utilization and unit costs before and after implementation will be collated from hospital records, and state and national health service administrative datasets. Qualitative data from patients, consumers and clinicians before and after practice change will be gathered through interviews and focus groups.

Discussion

The study outcomes will detail the impact and acceptability of the standardized integration of palliative care as a practice change, including recommendations for ongoing sustainability and broader implementation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN 12619001703190. Registered 04 December 2019.

Palliative Care Professionals' Message to Others: An Ethnographic Approach

INTRODUCTION

Palliative care continues to be misunderstood within the world of healthcare. Palliative care professionals are key agents for promoting a greater understanding of their field. This study aims to examine the messages, both implicit and explicit, that palliative care professionals transmit about themselves and their work within their teams and to other health professionals.

METHODS

Focused ethnographic secondary analysis, exploring the interactions of palliative care professionals as it happens at everyday work. An inductive thematic analysis was developed from 242 h of observation of the daily work practices of palliative care professionals, focusing on their interactions with others. The data was coded without predefined categories, and the analysis was performed independently by two researchers.

RESULTS

Palliative professionals communicate that they are part of an active team working in an organized manner. They value and feel proud of their work. Despite the intensity of their work, these professionals are always available to others, to whom they demonstrate a clear professional identity. They convey their expertise in alleviating suffering, respectful behavior and collaborative ability.

CONCLUSION

Professionals, in their daily work, communicate through their messages the essence of palliative care. It is essential that palliative care professionals perceive themselves as potential influencers and explicitly transmit the reasons for their intervention. Otherwise, others will perpetuate the myths, misunderstandings, and lack of a positive reputation for palliative care.

The impact of public health palliative care interventions on health system outcomes: A systematic review

BACKGROUND

Public health palliative care interventions are increasingly implemented, with growing recognition of the importance of building evidence to support their utility in end-of-life care. Previous efforts have focused on community outcomes.

AIM

To examine the impact of public health palliative care on patterns of health service use at the end of life (primary) and explore which outcomes are being measured within this field of research (secondary).

DESIGN

Systematic review of studies reporting qualitative and quantitative data, analysed with a narrative synthesis method.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using six electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, INFORMIT and COCHRANE) up to February 2020.

RESULTS

Searches yielded 2622 unique titles screened for eligibility, resulting in 35 studies measuring outcomes from a public health palliative care approach. Five (14%) studies assessed health system outcomes, and three reported some mixed evidence of impact, including reduced hospital emergency admissions, hospital bed days, hospital costs and increased home deaths. Most studies (86%) instead reported on conceptual (49%), knowledge (40%), programme participation (37%) and/or individual health outcomes (29%).

CONCLUSION

The impact of public health palliative care is an evolving area of empirical inquiry with currently only limited evidence that it improves healthcare utilisation outcomes at the end of life, and limited focus on measurement of these outcomes. Further empirical studies are needed to support the reorientation of health services, which remains an important component in realising 'whole of system change' to bring about quality end-of-life care for all.

A randomised phase II trial testing the acceptability and feasibility of a narrative approach to public health communication to increase community engagement with palliative care

BACKGROUND

Communities have limited understanding of palliative care, creating barriers to informed choice around consideration of a full range of care options in the event of serious illness. Few empirically tested interventions are available to educate community about palliative care, and ultimately improve timely access to these services.

AIM

To test the acceptability (primary outcome), and feasibility of a narrative approach to public health communication seeking to improve attitudes to possible access to palliative care in the event of serious illness.

DESIGN

Randomised phase II trial with six parallel experimental conditions. Outcomes tested included measures of acceptability, feasibility and change in attitudes to possible access to palliative care post-intervention. Contrasts planned for exploratory testing included format, message content and narrator.

SETTING/PARTICIPANTS

Community-based sample of consecutive English-speaking adults who volunteered their participation in response to a study advertisement distributed online through established community groups.

RESULTS

A narrative approach to public health communication was found to be acceptable to community members, and feasible to deliver online. Exploratory data suggested it immediately improved attitudes towards possible access to palliative care in the event of serious illness, with the narrative detailing a description of the evidence delivered by a healthcare professional appearing to be the most promising strategy.

CONCLUSIONS

This study provides preliminary data to inform a future, longitudinal trial evaluating effectiveness and ultimately other evidence-based, public health approaches to improve community engagement with palliative care. Further studies are required to confirm the generalisability of findings to a broader representative sample and other settings including internationally.

Palliative care utilisation: family carers' behaviours and determinants-a qualitative interview study

OBJECTIVES

Most research on starting palliative care focuses on the role of healthcare services and professional carers. However, patients and their family carers may also play a role. Especially opportunities for starting palliative care might exist among family carers. This study focused on family carers by identifying their behaviours and underlying determinants that might contribute to starting palliative care.

METHODS

A qualitative study with 16 family carers of deceased persons who used palliative care was conducted using semistructured, face-to-face interviews. Constant comparison analysis was used to identify groups of behaviours that influenced starting palliative care and related determinants. The behavioural determinants were matched with concepts in existing behavioural theories. A preliminary behavioural model was developed.

RESULTS

Most reported behaviours regarding starting palliative care were related to communicating with the seriously ill person, other family members and professional carers; seeking information and helping the seriously ill person process information from professional carers; and organising and coordinating care. Determinants facilitating and hindering these behaviours included awareness (eg, of poor health), knowledge (eg, concerning palliative care), attitudes (eg, negative connotations of palliative care) and social influences (eg, important others' opinions about palliative care).

CONCLUSIONS

This study identified relevant family carers' behaviours and related determinants that can contribute to starting palliative care. As these determinants are changeable, the palliative care behavioural model that resulted from this study can serve as a basis for the development of behavioural interventions aiming at supporting family carers in performing behaviours that might contribute to starting palliative care.

"The way I am treated is as if I am under my mother's care": qualitative study of patients' experiences of receiving hospice care services in South Africa

Background

Research on the patient experience of receiving palliative care across a number of settings is increasing, but the majority of these investigations are situated within the context of developed countries. There is limited research from resource-limited countries, especially with regard to patients with cancer who receive hospice care. The present study explored the lived experience of attending hospice care facilities in South Africa to develop a bottom-up understanding from the perspectives of patients themselves.

Methods

A qualitative cross-sectional study was designed to examine how patients experienced receiving hospice care We conducted in-depth, semi-structured interviews with thirteen, purposively selected patients living with terminal cancer and receiving in-patient or day care palliative services from a hospice organisation in South Africa. We used inductive thematic analysis to analyse the data.

Results

We identified three themes that reflected a process of transformation that was experienced by participants during their engagement with the hospice services. The first theme describes participants’ initial reluctance to be linked to the hospice as a result of the stereotypic perceptions of hospice as being associated with death and dying. The second theme presents the perceived positive impact on patients’ physical and psychosocial wellbeing which resulted from the highly valued interactions with staff and other patients as well as patients’ engagement with creative activities. The final theme delineates the transformation of hospice into a second ‘family’ and ‘home’ and the restoration of an identity that expands beyond the ‘sick’ role.

Conclusions

Receiving hospice care that sensitively attends to patients’ psychosocial and physical needs helps people to re-create a sense of homeliness within the world, re-orient themselves toward a meaningful life and re-configure their relationship with self. Patient experience of receiving hospice care in South Africa does not appear dissimilar to that reported by patients in resource-rich countries, suggesting underlying commonalities. There is a need for raising awareness and educating the public about what palliative care can offer to those in need. Public health campaigns could help reduce the stigma attached to palliative care, deflect negative perceptions, and communicate the benefits for patients, families and communities in culturally sensitive ways.

Palliative care in its own discourse: a focused ethnography of professional messaging in palliative care

Background

Despite 50 years of modern palliative care (PC), a misunderstanding of its purpose persists. The original message that PC is focused on total care, helping to live until the person dies, is being replaced and linked to feelings of fear, anxiety and death, instead of compassion, support or appropriate care. Society is still afraid to speak its name, and specialized units are identified as “places of death” as opposed to “places of life” meant to treat suffering. This issue is prohibitive to the implementation and development of PC policies worldwide. It is imperative to identify what message PC professionals are relaying to patients and other health care specialists and how that message may condition understandings of the right to access PC.

Methods

A qualitative study, employing focused ethnography and participant observation (PO) of the daily interaction of PC professionals with patients and family members in three different PC services. Two researchers independently conducted a thematic analysis, followed by member checking with participants.

Results

A total of 242 h of participant observation revealed the following messages sent by PC professionals in their daily interaction with patients and families: i) We are focused on your wellbeing; ii) You matter: we want to get to know you; iii) Your family is important to us.

Conclusion

The complexity of PC discourses contributes to the difficulty of identifying a clear universal message between PC professionals, patients and families. The PC professionals observed transmit a simple message focused on their actions rather than their identity, which may perpetuate some social/cultural misunderstandings of PC. It seems there is a common culture, based on the same values and attitudes, within the messages that PC professionals transmit to patients and their families. PC teams are characterised by their availability.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

"I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care

BACKGROUND

Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear.

AIM

To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses.

DESIGN

A constructivist qualitative grounded theory study was conducted.

SETTING/PARTICIPANTS

A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center.

RESULTS

The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward.

CONCLUSION

Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Community knowledge of and attitudes to palliative care: A descriptive study

BACKGROUND

Palliative care is predominantly accessed late in the course of an illness, despite evidence to suggest the benefits of early engagement. Strategies are required to reduce the barriers to the delivery of palliative care.

AIM

To describe community understandings of and attitudes to palliative care and explore characteristics significantly associated with favourable attitudes towards palliative care.

DESIGN

Cross-sectional survey data were collected including several sociodemographic characteristics, knowledge of palliative care and attitudes to palliative care. Correlational analyses identified factors related to positive attitudes to palliative care. Those of significance (p ⩽ 0.01) were examined using a multiple regression model to determine their predictive value.

SETTING/PARTICIPANTS

A community-based sample of consecutive English-speaking adults who volunteered their participation in response to a study advertisement distributed online through established community groups.

RESULTS

A total of 421 participants (75% female, mean age: 51 ± 15.1) reported a median of at least three misperceptions of palliative care. Older age, previously undertaking a caregiving role, knowing someone who had received palliative care and reporting more accurate knowledge of palliative care significantly predicted favourable attitudes to palliative care (adjusted R² = 0.24, F(8, 333) = 13.2, p < 0.001). Other factors typically associated with health literacy such as tertiary education, working at a medical facility and speaking a language other than English at home were not predictive.

CONCLUSION

Gaps in knowledge about palliative care exist in community, which may limit citizen's potential access to quality care in the event of serious illness. These results point to a role for public education programmes, which may, in turn, also shift attitudes to palliative care.

Development and Validation of the Palliative Care Attitudes Scale (PCAS-9): A Measure of Patient Attitudes Toward Palliative Care

CONTEXT

Palliative Care is underutilized, and research has neglected patient-level factors including attitudes that could contribute to avoidance or acceptance of Palliative Care referrals. This may be due in part to a lack of existing measures for this purpose.

OBJECTIVES

The objective of this study was to develop and validate a nine-item scale measuring patient attitudes toward Palliative Care, comprised of three subscales spanning emotional, cognitive, and behavioral factors.

METHODS

Data were collected online in three separate waves, targeting individuals with cancer (Sample 1: N = 633; Sample 2: N = 462) or noncancer serious illnesses (Sample 3: N = 225). Participants were recruited using ResearchMatch.org and postings on the web sites, social media pages, and listservs of international health organizations.

RESULTS

Internal consistency was acceptable for the total scale (α = 0.84) and subscales: emotional (α = 0.84), cognitive (αs = 0.70), and behavioral (α = 0.90). The PCAS-9 was significantly associated with a separate measure of Palliative Care attitudes (ps < 0.001) and a measure of Palliative Care knowledge (ps < 0.004), supporting its construct validity in samples of cancer and noncancer serious illnesses. The scale's psychometric properties, including internal consistency and factor structure, generalized across patient subgroups based on diagnosis, other health characteristics, and demographics.

CONCLUSION

Findings support the overall reliability, validity, and generalizability of the PCAS-9 in serious illness samples and have implications for increasing Palliative Care utilization via clinical care and future research efforts.

Knowledge of and beliefs about palliative care in a nationally-representative U.S. sample

Palliative care aims to improve quality of life for people with serious illness and their families. One potential barrier to palliative care uptake is inaccurate knowledge and/or negative beliefs among the general population, which may inhibit early interest in, communication about, and integration of palliative care following subsequent illness diagnosis. We explored knowledge and beliefs about palliative care among the general public using nationally-representative data collected in 2018 as part of the cross-sectional Health Information National Trends Survey. Only individuals who had heard of palliative care (n = 1,162, Mage = 51.8, 64% female) were queried on knowledge and beliefs. We examined whether self-assessed level of awareness of palliative care (i.e., knowing a little vs. enough to explain it) was associated with the relative likelihood of having accurate/positive beliefs, inaccurate/negative beliefs, or responding "don't know" to questions about palliative care. Respondents who indicated knowing a lot about palliative care had more accurate versus inaccurate knowledge than those who knew a little on only two of six items and more positive attitudes on only one of three items. In particular, respondents with greater awareness were equally likely to report that palliative care is the same as hospice and requires stopping other treatments, and equally likely to believe that palliative care means giving up and to associate palliative care with death. Those with higher awareness were less likely than those with lower awareness to respond "don't know," but greater awareness was not necessarily associated with having accurate or positive beliefs about palliative care as opposed to inaccurate or negative beliefs. Thus, even members of the general public who perceived themselves to know a lot about palliative care were often no less likely to report inaccurate knowledge or negative beliefs (versus accurate and positive, respectively). Findings suggest a need to improve awareness and attitudes about palliative care.

The conceptual understanding of pediatric palliative care: a Swiss healthcare perspective

Background

Health care providers’ perception of pediatric palliative care might negatively influence timely implementation. The aim of the study was to examine understanding of and attitudes towards pediatric palliative care from the perspective of health care providers working in pediatric oncology in Switzerland to promote the timely implementation of pediatric palliative care.

Methods

Five mixed focus groups were conducted with 29 health care providers (oncologists, nurses, psychologists, and social workers) at five Swiss pediatric oncology group centers. The focus group interviews were analyzed using thematic coding.

Results

Most participants associated pediatric palliative care with non-curative treatment. They regularly reported difficulties in addressing palliative care services to families due to the strong stigma surrounding this term. They also thought that the notion of palliative care is very much linked to a policy context, and difficult to reconcile with children’s everyday life. To overcome these obstacles many participants used synonyms such as comfort or supportive care. A few providers insisted on the need of using palliative care and reported the importance of positive “word of mouth”.

Conclusions

The use of synonyms might be a pragmatic approach to overcome initial barriers to the implementation of palliative care in pediatrics. However, this tactic might ultimately prove to be ineffective as these terms might acquire the same negative connotations as palliative care. Positive word-of-mouth by satisfied families and healthcare providers might be a more sustainable way to advocate for pediatric palliative care than replacing it with a euphemistic term.