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De Souza J, Gillett K, Salifu Y, Walshe C. Living and dying between cultural traditions in African & Caribbean Heritage families: a constructivist grounded theory. BMC Palliat Care 2024; 23:176. [PMID: 39026241 PMCID: PMC11256641 DOI: 10.1186/s12904-024-01503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 07/08/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Ethnic differences influence end-of-life health behaviours and use of palliative care services. Use of formal Advance care planning is not common in minority ethnic heritage communities. Older adults expect and trust their children to be their decision makers at the end of life. The study aim was to construct a theory of the dynamics that underpin end-of-life conversations within families of African and Caribbean heritage. This is a voice not well represented in the current debate on improving end-of-life outcomes. METHODS Using Charmaz's constructivist grounded theory approach, a purposive sample of elders, adult-children, and grandchildren of African and Caribbean Heritage were recruited. In-person and online focus groups were conducted and analysed using an inductive, reflexive comparative analysis process. Initial and axial coding facilitated the creation of categories, these categories were abstracted to constructs and used in theory construction. RESULTS Elders (n = 4), adult-children (n = 14), and adult grandchildren (n = 3) took part in 5 focus groups. A grounded theory of living and dying between cultural traditions in African and Caribbean heritage families was created. The constructs are (a) Preparing for death but not for dying (b) Complexity in traditions crosses oceans (c) Living and dying between cultures and traditions (d) There is culture, gender and there is personality (e) Watching the death of another prompts conversations. (f) An experience of Hysteresis. DISCUSSION African and Caribbean cultures celebrate preparation for after-death processes resulting in early exposure to and opportunities for discussion of these processes. Migration results in reforming of people's habitus/ world views shaped by a mixing of cultures. Being in different geographical places impacts generational learning-by-watching of the dying process and related decision making. CONCLUSIONS Recognising the impact of migration on the roles of different family members and the exposure of those family members to previous dying experiences is important. This can provide a more empathetic and insightful approach to partnership working between health care professionals and patients and families of minority ethic heritage facing serious illness. A public health approach focusing on enabling adult-children to have better end of life conversations with their parents can inform the development of culturally competent palliative care.
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Affiliation(s)
- Joanna De Souza
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
- King's College London, Nursing, Midwifery & Palliative Care, London, UK.
| | - Karen Gillett
- King's College London, Nursing, Midwifery & Palliative Care, London, UK
| | - Yakubu Salifu
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Catherine Walshe
- International Observatory on End-of-Life Care, Division of Health Research, Lancaster University, Lancaster, UK
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Izumi S(S, Garcia E, Kualaau A, Sloan DE, DeSanto-Madeya S, Candrian C, Anderson E, Sanders J. Advance care planning as perceived by marginalized populations: Willing to engage and facing obstacles. PLoS One 2024; 19:e0301426. [PMID: 38557983 PMCID: PMC10984538 DOI: 10.1371/journal.pone.0301426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Health disparities exist in end-of-life (EOL) care. Individuals and communities that are marginalized due to their race, ethnicity, income, geographic location, language, or cultural background experience systemic barriers to access and receive lower quality EOL care. Advance care planning (ACP) prepares patients and their caregivers for EOL decision-making for the purpose of promoting high-quality EOL care. Low engagement in ACP among marginalized populations is thought to have contributed to disparity in EOL care. To advance health equity and deliver care that aligns with the goals and values of each individual, there is a need to improve ACP for marginalized populations. AIM To describe how patients from marginalized populations experience and perceive ACP. METHODS We used an interpretive phenomenological approach with semi-structured qualitative interviews. Participants were recruited from four primary care clinics and one nursing home in a US Pacific Northwest city. Thirty patients from marginalized populations with serious illness participated in individual interviews between January and December 2021. Participants were asked to describe their experiences and perceptions about ACP during the interviews. RESULTS The mean age of 30 participants was 69.5; 19 (63%) were women; 12 (40%) identified as Asian/Pacific Islanders, 10 (33%) as Black; and 9 (30%) were non-native English speakers. Our three key findings were: 1) patients from marginalized populations are willing to engage in ACP; 2) there were multiple obstacles to engaging in ACP; and 3) meaningful ACP conversations could happen when clinicians listen. Although participants from marginalized populations were willing to engage in ACP, a fragmented and restrictive healthcare system and clinicians' biased behaviors or lack of interest in knowing their patients were obstacles. Participants who felt their clinicians took time and listened were encouraged to engage in ACP. CONCLUSION Patients from marginalized populations are willing to engage in ACP conversations despite a common belief otherwise. However, obstacles to meaningful ACP conversations with healthcare providers exist. Clinicians need to be aware of these obstacles and listen to build trust and engage marginalized patients in mutually meaningful ACP conversations.
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Affiliation(s)
- Shigeko (Seiko) Izumi
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Ellen Garcia
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Andrew Kualaau
- School of Nursing, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Danetta E. Sloan
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Susan DeSanto-Madeya
- College of Nursing, University of Rhode Island, Providence, Rhode Island, United States of America
| | - Carey Candrian
- School of Medicine, University of Colorado, Aurora, Colorado, United States of America
| | - Elizabeth Anderson
- Pacific Institute for Research and Evaluation, Louisville, Kentucky, United States of America
| | - Justin Sanders
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Anandarajah G, Mennillo MR, Wang S, DeFries K, Gottlieb JL. Trust as a Central Factor in Hospice Enrollment Disparities Among Ethnic and Racial Minority Patients: A Qualitative Study of Interrelated and Compounding Factors Impacting Trust. J Palliat Med 2023; 26:1488-1500. [PMID: 37379486 DOI: 10.1089/jpm.2023.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Abstract
Background: Disparities in end-of-life (EOL) care remain among ethnic/racial minority populations. Choosing hospice care in the United States depends on goals-of-care discussions founded on trust. While studies examine hospice enrollment disparities and others explore trust in hospice settings in general, very few explicitly examine the role of trust in hospice enrollment disparities. Objectives: To explore factors impacting trust and how these might contribute to disparities in hospice enrollment. Design: A qualitative, individual interview study, based on grounded theory. Setting/Subjects: Setting: Rhode Island, USA. Participants: Multiple stakeholders in EOL care, with diverse professional and personal backgrounds. Measurements: In-depth semistructured individual interviews were audio-recorded and transcribed as part of a broader study of hospice enrollment barriers in diverse patients. Analysis: Five researchers did a secondary data analysis, focusing on trust as the central phenomenon of interest. Researchers independently analyzed transcripts, then held iterative group analysis meetings until they reached consensus regarding themes, subthemes, and relationships. Results: Twenty-two participants included five physicians, five nurses, three social workers, two chaplains, one nursing assistant, three administrators, and three patient caregivers/family. Interviews reveal that trust is multidimensional, involving personal- and systems-level trust, and both locus and degree of trust. Factors impacting trust include: fear; communication/relationships; knowledge of hospice; religious/spiritual beliefs; language; and cultural beliefs/experiences. While some are common across groups, several are more prevalent in minority populations. These factors appear to interact in complex ways, unique to individual patients/families, compounding their impact on trust. Conclusions: While gaining patient/family trust regarding EOL decision making is challenging across all groups, minority patients often experience additional compounding factors impacting trust building. More research is needed to mitigate the negative ways these interacting factors impact trust.
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Affiliation(s)
- Gowri Anandarajah
- Department of Family Medicine and Medical Science, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Meera R Mennillo
- Department of English, University of Rhode Island, Kingston, Rhode Island, USA
| | - Sophie Wang
- Department of Medical Sciences, Brown University Graduate School, Providence, Rhode Island, USA
| | - Kai'olu DeFries
- Department of Medical Sciences, Brown University Graduate School, Providence, Rhode Island, USA
| | - Jaya L Gottlieb
- Department of Biology, University of Massachusetts-Amherst, Amherst, Massachusetts, USA
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Demirkapu H, Hajji R, Chater B, De Maesschalck S, Van den Block L, De Vleminck A, Devroey D. Advance care planning among older adults of Moroccan origin: An interview-based study. PATIENT EDUCATION AND COUNSELING 2023; 113:107794. [PMID: 37196404 DOI: 10.1016/j.pec.2023.107794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 04/12/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To explore advance care planning (ACP)-related knowledge, experience, views, facilitators and barriers among older Moroccan adults in Belgium. METHOD General practitioners (GPs) recruited participants for semi-structured interviews. Data were analysed using the constant comparative method. RESULTS The 25 interviewees (average age, 74 years) lacked ACP knowledge and had not discussed it with healthcare professionals. After a brief explanation, most interviewees did not find ACP useful. After more explanation with a specific example, they had fewer religious objections and were more willing to have discussions with their GPs and/or relatives. ACP barriers were a lack of knowledge, current good health, potential harm of talking about death, trust in one's children to make care decisions and fear of worrying one's children. Facilitators were GPs' information provision, children's involvement in ACP discussions and the desire to not depend on children. CONCLUSION Many older Moroccan adults lacked familiarity, but were willing to discuss ACP after receiving understandable concrete information. GPs should facilitate ACP discussions for these patients, ideally with adult children involved, with consideration of barriers, individual preferences and generally low educational levels. PRACTICE IMPLICATIONS GPs should provide comprehensible ACP information with case examples and consider potential barriers and facilitators in this group.
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Affiliation(s)
- Hakki Demirkapu
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium.
| | - Redouan Hajji
- Academic Center for General Practice KU Leuven, Leuven, Belgium
| | - Brahim Chater
- Academic Center for General Practice KU Leuven, Leuven, Belgium
| | | | - Lieve Van den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, and Ghent University, Ghent, Belgium
| | - Aline De Vleminck
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, and Ghent University, Ghent, Belgium
| | - Dirk Devroey
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Brussels, Belgium
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Jeon H, Kim S, Lee I. "The communication I had with him back then is still stuck in my mind." Bereaved families of cancer patients' experiences for end-of-life communication. Support Care Cancer 2023; 31:277. [PMID: 37071223 PMCID: PMC10111311 DOI: 10.1007/s00520-023-07753-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 04/13/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE Communication with family members is important to end-of-life care for patients with cancer. It is an interactive engagement between terminally-ill cancer patients and their families through which they expand their mutual understanding to cope with losses and find meaning in death. This study aimed to describe the experiences of end-of-life communication between patients with cancer and their family members in South Korea. METHODS This is a qualitative descriptive study using in-depth semi-structured interviews. Ten bereaved family members with end-of-life communication experience with terminal cancer patients were recruited through purposive sampling. Data were analyzed using qualitative content analysis. RESULTS A total of 29 constructed meanings, 11 sub-categories, and the following 3 categories were derived: "Offering a space for patients to reminisce and reflect," "Building a bond," and "Reflections on what we need." End-of-life communication primarily centered on the patients, with families struggling to share their stories with them. Although the families coped well, they also regretted the lack of meaningful communication with the patients, indicating a need for support to facilitate effective end-of-life communication. CONCLUSION The study highlighted concrete communication for finding meaning at the end-of-life for cancer patients and their families. We found that the families have the potential to communicate appropriately to cope with the patients' end-of-life. Nevertheless, end-of-life presents a unique challenge in which families require adequate support. Given the increasing number of patients and families dealing with end-of-life care in hospitals, healthcare providers should be mindful of their needs and help them cope effectively.
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Affiliation(s)
- Heejung Jeon
- Department of Nursing, Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Sanghee Kim
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Ilhak Lee
- Division of Medical Law and Ethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Asian Institute for Bioethics and Health Law, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, Republic of Korea.
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Iguina MM, Danyalian AM, Luque I, Shaikh U, Kashan SB, Morgan D, Heller D, Danckers M. Characteristics, ICU Interventions, and Clinical Outcomes of Patients With Palliative Care Triggers in a Mixed Community-Based Intensive Care Unit. J Palliat Care 2023; 38:126-134. [PMID: 36632687 DOI: 10.1177/08258597221145326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective: Integration of palliative care initiatives in the intensive care unit (ICU) benefit patients and improve outcomes. Palliative care triggers (PCTs) is a screening tool that aides in stratifying patients who would benefit most from an early palliative care approach. There is no consensus on PCT selection or best timing for implementation. We evaluated the clinical characteristics, ICU and palliative care interventions, and clinical outcomes of critically ill patients with PCT in a community-based mixed ICU. Methods: This retrospective study was conducted in a 44-bed adult, mixed ICU in a 407-bed community-based teaching hospital in Florida. Eleven PCTs were used as a screening tool during multidisciplinary rounds (MDRs). Patients were analyzed based on presence or absence of PCT as well as having met high (>2) versus low (<2) PCT. Data collected included patient demographics, ICU resource utilization and clinical outcomes. We considered a two-sided P value of less than .05 to indicate statistical significance with a 95% confidence interval. Results: Of 388 ICU patients, 189 (48.7%) met at least 1 PCT and 199 (51.3%) did not. The trigger group had higher Acute Physiology and Chronic Evaluation (APACHE) and Sequential Organ Failure Assessment (SOFA) scores within 24 h of ICU admission. The most common PCTs identified were ICU length of stay greater than 7 days or readmission to ICU, terminal prognosis and assisting family in transitioning goals of care. There were statistically significant differences in ICU resource utilization, palliative care interventions, and overall worse clinical outcomes in the trigger-detected group. Similar findings were seen in the cohort with high PCT (>2). Conclusions: Our study supports the implementation of a tailored 11-item palliative care screening tool to effectively identify ICU patients with high ICU and palliative care interventions and worse clinical outcomes.
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Affiliation(s)
- Michele M Iguina
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Aunie M Danyalian
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Ilko Luque
- Research Department, Graduate Medical Education, HCA East Florida Division, 23686Aventura Hospital and Medical Center, Aventura, FL, USA
| | - Umair Shaikh
- Department of Medicine, Piedmont Eastside Medical Center, Snellville, GA, USA
| | - Sanaz B Kashan
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Dionne Morgan
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Daniel Heller
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
| | - Mauricio Danckers
- Department of Medicine, HCA Florida Aventura Hospital, Aventura, FL, USA
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, FL, USA
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Hirata M, Kobayashi K. Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography. J Pediatr Nurs 2022; 69:e45-e64. [PMID: 36586777 DOI: 10.1016/j.pedn.2022.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Decision-making during the end-of-life (EOL) phase for children with cancer is extremely difficult for parents. We synthesized the qualitative experiences of children with cancer, parents, and healthcare professionals (HCPs), and their social interactions during the EOL decision-making process in the pediatric oncology setting. METHODS Meta-ethnography was used to conduct a systematic review and meta-synthesis. We searched four online databases to identify original studies published in English and Japanese and examined 21 relevant studies. Two Japanese reviewers discussed the differences/relationships and included studies that synthesized the translated qualitative findings. A conceptual model of social interactions was created. RESULTS We identified four themes regarding children's, parents', and HCPs' experiences: hope and confrontation with the child's death, guidance and support during uncertainty, awareness of being protected and having hope, and mutual unspoken integration of values. CONCLUSIONS These themes evince the experiences of children, parents, and HCPs during the EOL decision-making process and suggests a complex three-way social interaction model. While considering such distinctive social interactions during a child's EOL, this study revealed the sharing of prudent information and psychosocial support by HCPs. The findings indicate that hope and uncertainty are key elements for effectively understanding the experiences of children and parents and that EOL decision-making should not be rushed but should be supported by leaving room for uncertainty and acknowledging parents' emotional needs and fostering new hope. Further research into how hope can be further supported in situations that are rife with uncertainty is needed.
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Affiliation(s)
- Mika Hirata
- Department of Nursing, School of Health and Social Services, Saitama Prefectural University, 820 Sannomiya, Koshigaya-shi, Saitama 343-8540, Japan.
| | - Kyoko Kobayashi
- Graduate School of Nursing Science, St. Luke's International University, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan
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Armstrong M, Aker N, Nair P, Walters K, Barrado‐Martin Y, Kupeli N, Sampson EL, Manthorpe J, West E, Davies N. Trust and inclusion during the Covid-19 pandemic: Perspectives from Black and South Asian people living with dementia and their carers in the UK. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5689. [PMID: 35137453 PMCID: PMC9015357 DOI: 10.1002/gps.5689] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/26/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION People from ethnic minority backgrounds living with dementia are more likely to be diagnosed later and have less access to health and social care support than their White counterparts in the United Kingdom (UK). Covid-19 has exacerbated health inequalities and diminished trust from underserved communities in the government and health services. The wider aim of the study was to explore the impact of covid-19 on Black and South-Asian people living with dementia and their carers as well as exploring the experiences of dementia care. The present paper specifically explores their views on trust and mistrust using an ecological model. METHOD Semi-structured interviews were conducted with 11 family carers and four people living with dementia from South Asian or Black communities living in the community. Thematic analysis was used to analyse data. DESIGN An exploratory qualiative design was used. RESULTS Four main themes were developed exploring trust at the structural, organisational, community and individual level. At the structural level, participants discussed the inequity of Covid-19, some lack of trust in the UK Government and confusion in its messaging, and the anxiety sometimes leading to curtailment of media usage. At the organisational level, there was some evidence of a perceived lack of person-centred and culturally sensitive care from healthcare professionals, as well as concerns around care homes as places of safety. At the neighbourhood community level, participants discussed both a distrust as well as a strengthening of relationships and, at the individual level, factors such as knowledge of services, identity, and faith influenced their experience of the pandemic. CONCLUSIONS People living with dementia need support at all levels and this study highlights how the pandemic impacted each level. Ways to improve trust in the Government and health professionals alongside culturally adapted health messaging should be explored. Alongside this, an examination of how cultural values and norms may influence help-seeking responses to dementia and increase trust in services may be helpful post-pandemic.
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Affiliation(s)
- Megan Armstrong
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK
| | - Narin Aker
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK
| | - Pushpa Nair
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK
| | - Kate Walters
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK
| | - Yolanda Barrado‐Martin
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
| | | | - Emily West
- Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
| | - Nathan Davies
- Research Department of Primary Care and Population Health, Institute of Epidemiology and Health CareUniversity College London (UCL)LondonUK,Marie Curie Palliative Care Research Department, Division of PsychiatryUniversity College LondonLondonUK
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Aaron SP, Gazaway SB, Harrell ER, Elk R. Disparities and Racism Experienced Among Older African Americans Nearing End of Life. CURRENT GERIATRICS REPORTS 2021; 10:157-166. [PMID: 34956825 PMCID: PMC8685164 DOI: 10.1007/s13670-021-00366-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/23/2022]
Abstract
Purpose of Review The purpose of this review is to examine racism in healthcare as it relates to older African American adults. We focus on health disparities in old age and medical mismanagement throughout their lifespan. Recent Findings In the United States there have been extensive medical advances over the past several decades. Individuals are living longer, and illnesses that were deemed terminal in the past are now considered chronic illnesses. While most individuals living with chronic illness have experienced better quality of life, this is not the case for many African American older adults. Summary Older African American adults are less likely to have their chronic illness sufficiently managed and are more likely to die from chronic illnesses that are well controlled in Whites. African American older adults also continue to suffer from poorer healthcare outcomes throughout the lifespan to end-of-life.
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Affiliation(s)
- Siobhan P Aaron
- College of Nursing, University of Utah, 10 2000 E, Salt Lake City, UT 84112 U.S.A
| | - Shena B Gazaway
- School of Nursing, University of Alabama Birmingham, Birmingham, AL U.S.A
| | - Erin R Harrell
- Department of Psychology, University of Alabama, Tuscaloosa, AL U.S.A
| | - Ronit Elk
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL U.S.A
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Palliative Care Utilization Among Non-Western Migrants in Europe: A Systematic Review. J Immigr Minor Health 2021; 24:237-255. [PMID: 34709528 DOI: 10.1007/s10903-021-01302-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 10/20/2022]
Abstract
The paper aims to identify and describe the European evidence on opportunities and barriers to access and utilization of palliative care among non- western migrants. A systematic review in accordance with PRISMA guidelines was conducted in June 2020, searching Medline, CINAHL, PsychINFO and EMBASE databases. PROSPERO# CRD42020193651. Studies included empirical research published between 2011 and 2020. Search words were, for example, ethnic groups and palliative care. Thematic analysis was used to analyze data. Twenty nine qualitative and six quantitative studies were included. Four main themes were identified: communication and language; knowledge and awareness; patient preferences, cultural and religious issues; and lack of resources at different levels of palliative care service provision. Migrants' access to palliative care is impeded at system, community and individual levels, yet, recommendations are mostly at the individual level. Closer attention is required to these different levels when designing future palliative interventions for migrants.
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Takvorian SU, Bekelman J, Beidas RS, Schnoll R, Clifton ABW, Salam T, Gabriel P, Wileyto EP, Scott CA, Asch DA, Buttenheim AM, Rendle KA, Chaiyachati K, Shelton RC, Ware S, Chivers C, Schuchter LM, Kumar P, Shulman LN, O'Connor N, Lieberman A, Zentgraf K, Parikh RB. Behavioral economic implementation strategies to improve serious illness communication between clinicians and high-risk patients with cancer: protocol for a cluster randomized pragmatic trial. Implement Sci 2021; 16:90. [PMID: 34563227 PMCID: PMC8466719 DOI: 10.1186/s13012-021-01156-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/06/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Serious illness conversations (SICs) are an evidence-based approach to eliciting patients' values, goals, and care preferences that improve patient outcomes. However, most patients with cancer die without a documented SIC. Clinician-directed implementation strategies informed by behavioral economics ("nudges") that identify high-risk patients have shown promise in increasing SIC documentation among clinicians. It is unknown whether patient-directed nudges that normalize and prime patients towards SIC completion-either alone or in combination with clinician nudges that additionally compare performance relative to peers-may improve on this approach. Our objective is to test the effect of clinician- and patient-directed nudges as implementation strategies for increasing SIC completion among patients with cancer. METHODS We will conduct a 2 × 2 factorial, cluster randomized pragmatic trial to test the effect of nudges to clinicians, patients, or both, compared to usual care, on SIC completion. Participants will include 166 medical and gynecologic oncology clinicians practicing at ten sites within a large academic health system and their approximately 5500 patients at high risk of predicted 6-month mortality based on a validated machine-learning prognostic algorithm. Data will be obtained via the electronic medical record, clinician survey, and semi-structured interviews with clinicians and patients. The primary outcome will be time to SIC documentation among high-risk patients. Secondary outcomes will include time to SIC documentation among all patients (assessing spillover effects), palliative care referral among high-risk patients, and aggressive end-of-life care utilization (composite of chemotherapy within 14 days before death, hospitalization within 30 days before death, or admission to hospice within 3 days before death) among high-risk decedents. We will assess moderators of the effect of implementation strategies and conduct semi-structured interviews with a subset of clinicians and patients to assess contextual factors that shape the effectiveness of nudges with an eye towards health equity. DISCUSSION This will be the first pragmatic trial to evaluate clinician- and patient-directed nudges to promote SIC completion for patients with cancer. We expect the study to yield insights into the effectiveness of clinician and patient nudges as implementation strategies to improve SIC rates, and to uncover multilevel contextual factors that drive response to these strategies. TRIAL REGISTRATION ClinicalTrials.gov , NCT04867850 . Registered on April 30, 2021. FUNDING National Cancer Institute P50CA244690.
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Affiliation(s)
- Samuel U Takvorian
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA.
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.
| | - Justin Bekelman
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Penn Implementation Science Center, Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Penn Medicine Nudge Unit, Center for Healthcare Innovation, Penn Medicine, Philadelphia, PA, USA
| | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Center for Interdisciplinary Research on Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Alicia B W Clifton
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Tasnim Salam
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - E Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Center for Interdisciplinary Research on Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Callie A Scott
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Krisda Chaiyachati
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sue Ware
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Center for Interdisciplinary Research on Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Corey Chivers
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
| | - Lynn M Schuchter
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Pallavi Kumar
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
| | - Lawrence N Shulman
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Nina O'Connor
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
| | - Adina Lieberman
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Implementation Science Center, Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Penn Medicine Nudge Unit, Center for Healthcare Innovation, Penn Medicine, Philadelphia, PA, USA
| | - Kelly Zentgraf
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Implementation Science Center, Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
- Penn Medicine Nudge Unit, Center for Healthcare Innovation, Penn Medicine, Philadelphia, PA, USA
| | - Ravi B Parikh
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, 10S-113, Philadelphia, PA, 19104, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
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12
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Phillips AR, Reitz KM, Myers S, Thoma F, Andraska EA, Jano A, Sridharan N, Smith RE, Mulukutla SR, Chaer R. Association Between Black Race, Clinical Severity, and Management of Acute Pulmonary Embolism: A Retrospective Cohort Study. J Am Heart Assoc 2021; 10:e021818. [PMID: 34431356 PMCID: PMC8649302 DOI: 10.1161/jaha.121.021818] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Existing evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood. Methods and Results We retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02). Conclusions Black patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.
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Affiliation(s)
| | - Katherine M Reitz
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Sara Myers
- Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Floyd Thoma
- Division of Cardiology University of Pittsburgh Pittsburgh PA
| | | | - Antalya Jano
- School of Medicine University of Pittsburgh Pittsburgh PA
| | - Natalie Sridharan
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Roy E Smith
- School of Medicine University of Pittsburgh Pittsburgh PA.,Division of Hematology/Oncology University of Pittsburgh Pittsburgh PA
| | - Suresh R Mulukutla
- Division of Cardiology University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Rabih Chaer
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
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13
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Bazargan M, Bazargan-Hejazi S. Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature. Am J Hosp Palliat Care 2021; 38:688-718. [PMID: 33287561 PMCID: PMC8083078 DOI: 10.1177/1049909120966585] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks. METHODS The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks. DISCUSSION Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.
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Affiliation(s)
- Mohsen Bazargan
- Department of Family Medicine, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science (CDU), Los Angeles, CA, USA
- Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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14
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West E, Nair P, Barrado-Martin Y, Walters KR, Kupeli N, Sampson EL, Davies N. Exploration of the impact of the COVID-19 pandemic on people with dementia and carers from black and minority ethnic groups. BMJ Open 2021; 11:e050066. [PMID: 34006561 PMCID: PMC8136797 DOI: 10.1136/bmjopen-2021-050066] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/31/2021] [Accepted: 04/16/2021] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Despite community efforts to support and enable older and vulnerable people during the COVID-19 pandemic, many people with dementia and their family carers are still finding it difficult to adjust their daily living in light of the disruption that the pandemic has caused. There may be needs specific to black, Asian and minority ethnic (BAME) populations in these circumstances that remain thus far unexplored. OBJECTIVE The aim of the study was to explore the effects of the COVID-19 pandemic on people living with dementia and their family carers of BAME backgrounds, in relation to their experiences of community dementia care and the impact on their daily lives. DESIGN 15 participants (persons with dementia and carers) were recruited for semistructured qualitative interviews. Respondents were of South Asian and Afro-Caribbean backgrounds. We used thematic analysis to analyse our data from a constructivist perspective, which emphasises the importance of multiple perspectives, contexts and values. RESULTS There were a number of ways that the COVID-19 pandemic has impacted BAME persons with dementia and carers with regard to their experiences of dementia community care and the impact on their everyday lives. In particular we identified eight key themes, with subthemes: fear and anxiety, food and eating (encompassing food shopping and eating patterns), isolation and identity, community and social relationships, adapting to COVID-19, social isolation and support structures, and medical interactions. Fear and anxiety formed an overarching theme that encompassed all others. DISCUSSION This paper covers unique and underexplored topics in a COVID-19-vulnerable group. There is limited work with these groups in the UK and this is especially true in COVID-19. The results showed that such impacts were far-reaching and affected not only day-to-day concerns, but also care decisions with long-ranging consequences, and existential interests around fear, faith, death and identity.
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Affiliation(s)
- Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Pushpa Nair
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Kate R Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Division of Psychiatry, University College London, London, UK
| | - Nathan Davies
- Department of Primary Care and Population Health, University College London, London, UK
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15
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West E, Moore K, Kupeli N, Sampson EL, Nair P, Aker N, Davies N. Rapid review of decision-making for place of care and death in older people: lessons for COVID-19. Age Ageing 2021; 50:294-306. [PMID: 33336701 PMCID: PMC7799338 DOI: 10.1093/ageing/afaa289] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults. In the context of COVID-19, decision-making surrounding place of care (PoC) and place of death (PoD) in older adults involves significant new challenges. Aims To explore key factors that influence PoC and PoD decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19. Methods Rapid review of reviews, undertaken using WHO guidance for rapid reviews for the production of actionable evidence. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation. Results 10 papers were included for full data extraction. These papers were published between 2005 and 2020. Papers included discussed actual PoD, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Conclusions The process and outcomes of decision-making for older people are affected by many factors—all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.
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Affiliation(s)
- Emily West
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet, Enfield and Haringey Mental Health Liaison Service, North Middlesex University Hospital NHS Trust, London, UK
| | - Pushpa Nair
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Narin Aker
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Centre for ageing population Studies, Research Department of Primary Care and Population Health, University College London, London, UK
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16
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Andrews BL, Friedman Ross L. Black Women and Babies Matter. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:93-95. [PMID: 33534674 DOI: 10.1080/15265161.2020.1861384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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