1
|
Freund O, Sror N, Frydman S, Tellem R, Tchebiner J, Bornstein G, Zornitzki L. Attitudes of Patients with Advanced Chronic Illnesses Toward Palliative Extubation in a Country Where It Is Illegal. J Palliat Med 2024; 27:1043-1049. [PMID: 38722064 DOI: 10.1089/jpm.2024.0042] [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: 08/23/2024] Open
Abstract
Background: Palliative extubation (PE) is the cessation of mechanical ventilation (MV) during terminal illness. Although PE is widely practiced in many countries, it remains illegal in others. Attitudes toward PE of patients at the highest risk for MV were scarcely explored before. Objective: To assess the attitudes of patients with advanced chronic illnesses (ACI) toward PE and other end-of-life decisions in a country where PE is illegal. Design: A prospective observational study using questionnaire-based interviews. Setting/Subjects: Patients with ACI hospitalized between 2021 and 2022 in a large tertiary center. Attitudes toward PE and mechanical ventilation were evaluated. Predictors for favoring/opposing PE were analyzed using multivariate logistical regression models. Results: A total of 152 (40% female, 75 ± 11 years) patients were included. The most common ACIs were advanced heart failure (32%), metastatic malignancy (32%), and chronic obstructive pulmonary disease (22%). Around 132 patients (87%) supported the legalization of PE, and their main reason was to avoid pain and suffering (87%). Legalization of PE would change the decision to avoid mechanical intubation in 34% of the cases. Most patients thought that the decision to perform PE should be made by the patient's physician and primary caregiver collaboratively (64%). Religious observance was an independent predictor for opposing PE (adjusted odds ratio 0.18; 95% confidence interval 0.06-0.59; p < 0.01), whereas the type of ACI was not. Conclusion: Most admitted patients with ACIs support the legalization of PE. Such policy change could have major impact on patients' end-of-life preferences. At-risk patients should be the focus of future studies in this area.
Collapse
Affiliation(s)
- Ophir Freund
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neta Sror
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shir Frydman
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Tellem
- Palliative Care unit, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joseph Tchebiner
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Bornstein
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Zornitzki
- Department of Internal Medicine B, Tel Aviv Sourasky Medical Center, affiliated with the School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
2
|
Tripodoro VA, Veloso VI, Víbora Martín E, Kodba-Čeh H, Bakan M, Rasmussen BH, Zambrano SC, Joshi M, Hálfdánardóttir SÍ, Ásgeirsdóttir GH, Romarheim E, Haugen DF, McGlinchey T, Yildiz B, Barnestein-Fonseca P, Goossensen A, Lunder U, van der Heide A. 'Someone must do it': multiple views on family's role in end-of-life care - an international qualitative study. Palliat Care Soc Pract 2024; 18:26323524241260425. [PMID: 39099623 PMCID: PMC11295216 DOI: 10.1177/26323524241260425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/22/2024] [Indexed: 08/06/2024] Open
Abstract
Background Family is a crucial social institution in end-of-life care. Family caregivers are encouraged to take on more responsibility at different times during the illness, providing personal and medical care. Unpaid work can be overburdening, with women often spending more time in care work than men. Objectives This study explored multiple views on the family's role in end-of-life care from a critical perspective and a relational autonomy lens, considering gender in a socio-cultural context and applying a relational autonomy framework. It explored patients, relatives and healthcare providers' points of view. Design This qualitative study was part of the iLIVE project, involving patients with incurable diseases, their relatives and health carers from hospital and non-hospital sites. Methods Individual interviews of at least five patients, five relatives and five healthcare providers in each of the 10 participating countries using a semi-structured interview guide based on Giger-Davidhizar-Haff's model for cultural assessment in end-of-life care. Thematic analysis was performed initially within each country and across the complete dataset. Data sources, including researchers' field notes, were translated into English for international collaborative analysis. Results We conducted 158 interviews (57 patients, 48 relatives and 53 healthcare providers). After collaborative analysis, five themes were identified across the countries: family as a finite care resource, families' active role in decision-making, open communication with the family, care burden and socio-cultural mandates. Families were crucial for providing informal care during severe illness, often acting as the only resource. Patients acknowledged the strain on carers, leading to a conceptual model highlighting socio-cultural influences, relational autonomy, care burden and feminisation of care. Conclusion Society, health teams and family systems still need to better support the role of family caregivers described across countries. The model implies that family roles in end-of-life care balance relational autonomy with socio-cultural values. Real-world end-of-life scenarios do not occur in a wholly individualistic, closed-off atmosphere but in an interpersonal setting. Gender is often prominent, but normative ideas influence the decisions and actions of all involved.
Collapse
Affiliation(s)
- Vilma A. Tripodoro
- Instituto Pallium Latinoamérica, Bonpland 2287, Ciudad de Buenos Aires (1425), Argentina
- Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
- ATLANTES Global Observatory of Palliative Care, University of Navarra, Pamplona, Navarra, Spain
| | - Verónica I. Veloso
- Instituto Pallium Latinoamérica, Buenos Aires, Ciudad de Buenos Aires, Argentina
- Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | | | - Hana Kodba-Čeh
- University Clinic of Pulmonary and Allergic Diseases Golnik, Research Department, Golnik, Slovenia
| | - Miša Bakan
- University Clinic of Pulmonary and Allergic Diseases Golnik, Research Department, Golnik, Slovenia
| | - Birgit H. Rasmussen
- Institute for Palliative Care, Lund University and Region Skåne, Sweden
- Department of Health Sciences, Lund University, Sweden
| | - Sofía C. Zambrano
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- University Centre for Palliative Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Melanie Joshi
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Elisabeth Romarheim
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Dagny Faksvåg Haugen
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - Tamsin McGlinchey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Berivan Yildiz
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Urška Lunder
- University Clinic of Pulmonary and Allergic Diseases Golnik, Research Department, Golnik, Slovenia
| | | |
Collapse
|
3
|
Leiva O, Chukwusa E, Nkhoma K, Dittborn M, Turrillas P, Pastrana T. Opioid prescribing for cancer pain in Latin America: systematic review. BMJ Support Palliat Care 2024:spcare-2024-004999. [PMID: 38876507 DOI: 10.1136/spcare-2024-004999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/02/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To explore opioid prescribing patterns for cancer pain in Latin America (LA). METHODS A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Relevant databases, including MEDLINE, EMBASE, PubMed, LILACS and Scielo, were searched from inception to June 2023. Empirical studies of opioid prescription patterns in adult palliative care patients with cancer pain were included. Methodological quality was assessed using the Effective Public Health Practice Project tool. Data were analysed using narrative synthesis. Descriptive statistical analyses were conducted using SPSS V.28 (IBM). Categorical variables were summarised using frequencies and percentages and continuous variables as means or medians. RESULTS Seventeen studies from six countries were included. Ten were observational, while seven were experimental, including five randomised controlled trials (RCT) and two non-RCT. Most were low or moderate methodological quality. Out of 7809 patients, morphine (54%) and tramadol (18%) were the most prescribed opioids. The median of morphine equivalent daily dose was 26 mg (IQR 26-41). CONCLUSION Latin America shows lower opioid consumption rates compared with high-income countries for control pain management (CPM). More rigorous research on CPM in LA is needed. Additionally, a comprehensive review of opioid prescription patterns, including non-cancer diagnoses, is necessary.
Collapse
Affiliation(s)
- Ofelia Leiva
- Sección Medicina Palliativa, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | - Mariana Dittborn
- Centro de Bioética, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile
| | - Pamela Turrillas
- Superintendency of Pensions, Ministry of Labor and Social Security, Santiago, Chile
| | - Tania Pastrana
- Department of Palliative Medicine, RWTH Aachen University, Aachen, Germany
| |
Collapse
|
4
|
Pinto S, Lopes S, de Sousa AB, Delalibera M, Gomes B. Patient and Family Preferences About Place of End-of-Life Care and Death: An Umbrella Review. J Pain Symptom Manage 2024; 67:e439-e452. [PMID: 38237790 DOI: 10.1016/j.jpainsymman.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 02/05/2024]
Abstract
CONTEXT The place where people are cared towards the end of their life and die is a complex phenomenon, requiring a deeper understanding. Honoring preferences is critical for the delivery of high-quality care. OBJECTIVES In this umbrella review we examine and synthesize the evidence regarding preferences about place of end-of-life care and death of patients with life-threatening illnesses and their families. METHODS Following the Joanna Briggs Institute methodology, we conducted a comprehensive search for systematic reviews in PsycINFO, MEDLINE, EMBASE, CINAHL, Epistemonikos, and PROSPERO without language restrictions. RESULTS The search identified 15 reviews (10 high-quality, three with meta-analysis), covering 229 nonoverlapping primary studies. Home is the most preferred place of end-of-life care for both patients (11%-89%) and family members (23%-84%). It is also the most preferred place of death (patient estimates from two meta-analyses: 51%-55%). Hospitals and hospice/palliative care facilities are preferred by substantial minorities. Reasons and factors affecting preferences include illness-related, individual, and environmental. Differences between preferred places of care and death are underexplored and the evidence remains inconclusive about changes over time. Congruence between preferred and actual place of death ranges 21%-100%, is higher in studies since 2004 and a meta-analysis shows noncancer patients are at higher risk of incongruence than cancer patients (OR 1.23, 95% CI: 1.01-1.49, I2 = 62%). CONCLUSION These findings are a crucial starting point to address gaps and enhance strategies to align care with patient and family preferences. To accurately identify patient and family preferences is an important opportunity to change their lives positively.
Collapse
Affiliation(s)
- Sara Pinto
- Faculty of Medicine (S.P., S.L., A.B.S., M.D., B.G.), University of Coimbra, Azinhaga de Santa Comba, Coimbra, Portugal; Nursing School of Porto (S.P.), Rua Dr. António Bernardino de Almeida, Porto, Portugal; Cintesis@RISE, NursID (S.P.), Rua Dr. Plácido da Costa, Porto, Portugal
| | - Sílvia Lopes
- Faculty of Medicine (S.P., S.L., A.B.S., M.D., B.G.), University of Coimbra, Azinhaga de Santa Comba, Coimbra, Portugal; NOVA National School of Public Health, Public Health Research Center (S.L.), Universidade NOVA de Lisboa, Lisboa, Portugal; Comprehensive Health Research Center (S.L.), Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Andrea Bruno de Sousa
- Faculty of Medicine (S.P., S.L., A.B.S., M.D., B.G.), University of Coimbra, Azinhaga de Santa Comba, Coimbra, Portugal
| | - Mayra Delalibera
- Faculty of Medicine (S.P., S.L., A.B.S., M.D., B.G.), University of Coimbra, Azinhaga de Santa Comba, Coimbra, Portugal
| | - Barbara Gomes
- Faculty of Medicine (S.P., S.L., A.B.S., M.D., B.G.), University of Coimbra, Azinhaga de Santa Comba, Coimbra, Portugal; Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation (B.G.), King's College London, London, United Kingdom, Bessemer Road, SE5 9PJ, London, United Kingdom.
| |
Collapse
|
5
|
Pergolizzi J, LeQuang JAK, Wagner M, Varrassi G. Challenges in Palliative Care in Latin America: A Narrative Review. Cureus 2024; 16:e60698. [PMID: 38899235 PMCID: PMC11186623 DOI: 10.7759/cureus.60698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024] Open
Abstract
In "graying" populations with extended lifespans and survivable forms of cancer, palliative services become increasingly important but may be difficult to introduce into public discourse, public policy, and healthcare systems. Latin America (LATAM) faces many challenges as it introduces and, in some cases, develops its palliative care programs; though the challenges faced here are in many ways universal ones, LATAM approaches may be unique and based on the region's specific culture, politics, and economics. This narrative review based on a literature search identified 10 main themes that can be interpreted as challenges and opportunities for palliative care in LATAM. These challenges are integrating palliation into healthcare systems; public policy and funding; therapeutic obstinacy; changing demographics; access to services; analgesia; the role of religion, spirituality, and folk medicine; social determinants of palliative care; low health literacy; and limited clinician training. Some of the LATAM nations have palliative programs and palliative care training in place while others are developing these systems. Integrating this care into existing healthcare and reimbursement systems has been a challenge. A notable challenge in LATAM is also access to care since palliative programs tend to cluster in metropolitan areas and create hardships for rural citizens to access them. The better-defined role of familial caregivers and telehealth may be important factors in the expansion of palliative care in LATAM and beyond.
Collapse
Affiliation(s)
- Joseph Pergolizzi
- Anesthesiology - Pain Medicine and Critical Care Medicine, NEMA Research, Inc., Naples, USA
| | | | - Morgan Wagner
- Entrepreneur Program, NEMA Research, Inc., Naples, USA
| | | |
Collapse
|
6
|
Fu F, Ng YH, Wang J, Chui EWT. Journey to inpatient hospice care: A qualitative study on the decision-making process of Chinese family caregivers of persons with terminal cancer. PATIENT EDUCATION AND COUNSELING 2024; 119:108072. [PMID: 38048729 DOI: 10.1016/j.pec.2023.108072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/29/2023] [Accepted: 11/11/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To understand family caregivers' decision-making process to place their family members with terminal cancer in inpatient hospice care, especially in the social-cultural contexts whereby the caregivers have a dominant say about the care of their seriously ill family members. METHODS A qualitative study with a phenomenological approach was undertaken to understand the lived experience of caregivers of persons with terminal cancer in the decision-making process. Semi-structured qualitative interviews were conducted with a purposive sample of 17 caregivers in Shanghai, China. Thematic analysis was used to analyze the data. RESULTS The caregivers underwent a winding and socioculturally mediated four-stage process. The stages are (i) trigger for alternatives: lost hope for a cure, (ii) meandering the see-saw process, (iii) the last straws: physical limitations and witnessing unbearable suffering, and (iv) the aftermath: acceptance versus lingering hope. Caregivers' attitudes towards death and their family members with advanced cancer expressed care wishes influence the state of the aftermath. CONCLUSIONS Chinese sociocultural values and beliefs about caregiving and death provide insightful explanations for the observed process. PRACTICAL IMPLICATIONS Training healthcare professionals in cultural competence, developing an effective hospice referral system, and delivering socioculturally acceptable death education are critical interventions to facilitate better decision-making experiences.
Collapse
Affiliation(s)
- Fang Fu
- Social Work Department, School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Yong Hao Ng
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
| | - Juan Wang
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong.
| | - Ernest Wing-Tak Chui
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
| |
Collapse
|
7
|
Doubova SV, Bhadelia A, Pérez-Moran D, Martinez-Vega IP, García-Cervantes N, Knaul F. Dimensions of suffering and the need for palliative care: experiences and expectations of patients living with cancer and diabetes and their caregivers in Mexico - a qualitative study. BMJ Open 2023; 13:e075691. [PMID: 38101838 PMCID: PMC10729252 DOI: 10.1136/bmjopen-2023-075691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES Over 40 million people in low-income and middle-income countries (LMICs) experience serious health-related suffering (SHS) annually and require palliative care. Patient and caregiver experiences of SHS in LMICs are understudied despite their importance in guiding palliative care provision. Diabetes and cancer are the second-leading and third-leading causes of death in Mexico, causing a significant SHS burden on patients, families and health systems. This study examines SHS and palliative care from the point of view of patients with cancer and diabetes and their caregivers. DESIGN A qualitative descriptive study based on in-depth telephone interviews was conducted between August 2021 and February 2022. Data were analysed through inductive thematic analysis. PARTICIPANTS Overall, 20 patients with end-stage cancer, 13 patients with diabetes and 35 family caregivers were interviewed individually. SETTING Participants were recruited from two family medicine clinics and a pain clinic in Mexico City. RESULTS Seven themes emerged: (1) suffering as a multifaceted phenomenon, (2) diversity in perceptions of suffering, (3) different coping strategies, (4) need and perceived importance of relief from suffering, (5) barriers to accessing services to relieve suffering, (6) demand for the health sector's active and humane role in addressing suffering and (7) preferences and need for comprehensive care for relief from suffering. The primary coping strategies included family companionship, protective buffering and faith-based support. Participants lacked knowledge of palliative care. They expressed the importance of relief from suffering, viewing it as the health sector's responsibility and requesting more humane, personalised care and access to medicines and pain clinics. CONCLUSIONS The multifaceted nature of SHS highlights the health system's responsibility to provide high-quality palliative care. Policies to enhance access to palliative care should integrate it into primary care, redesigning services towards patient and caregiver biopsychosocial and spiritual needs and ensuring access to medicines and competent health personnel.
Collapse
Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico
| | - Afsan Bhadelia
- Department of Public Health. College of Health and Human Sciences, Purdue University, West Lafayette, Indiana, USA
| | - Diana Pérez-Moran
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico
| | - Ingrid Patricia Martinez-Vega
- Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Social Security Institute, Mexico City, Mexico
| | | | - Felicia Knaul
- Sylvester Comprehensive Cancer Centre, University of Miami, Miami, Florida, USA
- Institute for Advanced Study of the Americas, University of Miami, Coral Gables, Florida, USA
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
- Tómatelo a Pecho, Mexico City, CDMX, Mexico
- Fundación Mexicana para la Salud, Mexico City, CDMX, Mexico
| |
Collapse
|
8
|
Huang YL, Wang SY, Lin CC, Thorberg FA, Wu CJJ. Adults' perspectives of experiences and preferences for end-of-life care. Int J Palliat Nurs 2023; 29:588-596. [PMID: 38085613 DOI: 10.12968/ijpn.2023.29.12.588] [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: 12/18/2023]
Abstract
BACKGROUND Decisions about end-of-life care often raise clinical and ethical challenges, especially when the person's capacity to contribute in the decision making at the end of life is limited. AIM This study aimed to explore Taiwanese adults' preferences associated with communication, healthcare planning, life-sustaining treatments and palliative care and experiences of end-of-life care. METHODS Semi-structured interviews were conducted with 16 adults aged 20 years and above. The sampling approach was a convenience strategy in a community centre located in a metropolitan area in the Southern region of Taiwan. A qualitative content analysis approach was used to elicit key themes from the data. RESULTS Significant findings related to the two main themes of adults' experiences, including the observed distress of those who were dying and the distress experienced by the family. Other key findings pertain to personal preferences for end-of-life care, such as preferred end-of-life communication, preparing for the end-of-life and maintenance of quality of life. CONCLUSIONS This exploratory study offers insight into 16 Taiwanese community-dwelling adults' views of preferences regarding end-of-life communication, preparation for the end of life and maintenance of quality of life, as well as their experiences of end-of-life care. A further exploration is suggested to elicit how personal end-of-life experiences shape individuals' health practices in advance care planning for end-of-life care.
Collapse
Affiliation(s)
- Ya-Ling Huang
- Lecturer, Southern Cross University; Gold Coast Hospital and Health Service, Australia; Griffith University, Australia
| | - Shou-Yu Wang
- Senior Lecturer, University of New England, Australia
| | - Chun-Chih Lin
- Professor, Chang Gung University of Science and Technology, Taiwan; The new Taipei Municipal TuCheng Hospital, Built and Operated by Chang Gung Medical Foundation, Taiwan
| | | | - Chiung-Jung Jo Wu
- Associate Professor, School of Nursing, Midwifery, and Paramedicine, University of the Sunshine Coast, Australia; Royal Brisbane and Women's Hospital, Australia
| |
Collapse
|
9
|
Watanabe Y, Kawashima N, Uneno Y, Okamoto S, Muto M, Morita T. Determinants of Attitude Toward End-of-Life Care Among Junior Physicians: Findings from a Nationwide Survey in Japan. Palliat Med Rep 2023; 4:257-263. [PMID: 37732023 PMCID: PMC10507924 DOI: 10.1089/pmr.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/22/2023] Open
Abstract
Background Physicians' attitudes can be critical in quality end-of-life care. However, the determinants of the attitudes and whether the attitudes can be modified remain unclear. Objectives To investigate factors correlated with physicians' positive attitudes toward end-of-life care and whether these attitudes are modifiable through acquired factors (e.g., education or mentorship). Design A nationwide survey was conducted in 300 institutions and selected randomly from 1037 clinical training hospitals in Japan. Participants From each selected institution, two resident physicians of postgraduate year (PGY) 1 or 2 and two clinical fellows from PGY 3-5 were requested to answer the survey. Measurements The primary outcome was the Frommelt Attitudes Toward the Care of the Dying (FATCOD) scale score. Factors (e.g., the respondents' age, sex, number of years of clinical experience, training environment, religion, and beliefs around death) were examined for correlation with FATCOD score. Results In all, 198 physicians and 134 clinical fellows responded to the survey (response rate: 33.0% and 22.3%, respectively). Factors with the strongest correlation with FATCOD scores were mostly unmodifiable factors (e.g., being female and one's beliefs around death). Modifiable factors were also identified-number of patient deaths experienced, level of interest in palliative care, availability of support from senior mentors, and frequency of consultation with nonphysician medical staff. Conclusion Physicians' attitudes toward end-of-life care correlate more strongly with nonmodifiable factors, but attitudes can be meaningfully improved via mentoring by senior physicians. Future studies are warranted to determine the effective interventions to foster positive attitudes among physicians involved in end-of-life care.
Collapse
Affiliation(s)
- Yukiko Watanabe
- Faculty of Medicine, Okayama University Medical School, Okayama, Japan
| | | | - Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Soichiro Okamoto
- Medical Corporation Teieikai Chiba Home Care Clinic, Chiba, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuya Morita
- Division of Supportive and Palliative Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| |
Collapse
|
10
|
Pergolizzi J, LeQuang JAK, Coluzzi F, Magnusson P, Lara-Solares A, Varrassi G. Considerations for Pain Assessments in Cancer Patients: A Narrative Review of the Latin American Perspective. Cureus 2023; 15:e40804. [PMID: 37489190 PMCID: PMC10363018 DOI: 10.7759/cureus.40804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/21/2023] [Indexed: 07/26/2023] Open
Abstract
Cancer incidence in Latin America is lower than in Europe or the United States but morbidity and mortality rates are disproportionately high. A barrier to adequate pain control is inadequate pain assessment, which is a relatively easy and inexpensive metric. The objective of this narrative review is to describe pain assessment for cancer patients in Latin America. Cultural factors may influence pain perception, including contextualizing pain as noble or natural suffering and aspects of what is now called "spiritual pain." Unlike other painful conditions, cancer pain may be strongly associated with existential fear, psychosocial distress, anxiety, and spiritual concerns. Pain assessment allows not just quantification of pain intensity but may elucidate pain mechanisms involved or psychosocial aspects that may color the pain. Many current pain assessment instruments capture only pain intensity, which is but one aspect of the pain experience; some have expanded to include functional assessments, mental health status evaluations, and quality of life metrics. A quality-of-life assessment may be appropriate for cancer patients since chronic pain can severely impact function, which can in turn create a vicious cycle by exacerbating pain. The incidence of cancer in Latin America is expected to increase in the ensuing years. Better pain assessment and clinician education are needed to help manage pain in this large and growing patient population.
Collapse
Affiliation(s)
| | | | - Flaminia Coluzzi
- Medical and Surgical Sciences, Sapienza University of Rome, Rome, ITA
| | | | - Argelia Lara-Solares
- Pain and Palliative Care, National Institute of Medical and Nutritional Sciences, Mexico City, MEX
| | | |
Collapse
|
11
|
Mihailov E, Provoost V, Wangmo T. Acceptable objectives of empirical research in bioethics: a qualitative exploration of researchers' views. BMC Med Ethics 2022; 23:140. [PMID: 36575520 PMCID: PMC9794471 DOI: 10.1186/s12910-022-00845-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/19/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND This is the first qualitative study to investigate how researchers, who do empirical work in bioethics, relate to objectives of empirical research in bioethics (ERiB). We explore reasons that make some objectives more acceptable, while others are deemed less acceptable. METHODS Using qualitative exploratory study design, we interviewed bioethics researchers, who were selected to represent different types of scholars working in the field. The interview data of 25 participants were analyzed in this paper using thematic analysis. RESULTS From the eight objectives presented to the study participants, understanding the context of a bioethical issue and identifying ethical issues in practice received unanimous agreement. Participants also supported other objectives of ERiB but with varying degrees of agreement. The most contested objectives were striving to draw normative recommendations and developing and justifying moral principles. The is-ought gap was not considered an obstacle to ERiB, but rather a warning sign to critically reflect on the normative implications of empirical results. CONCLUSIONS Our results show that the most contested objectives are also the more ambitious ones, whereas the least contested ones focus on producing empirical results. The potential of empirical research to be useful for bioethics was mostly based on the reasoning pattern that empirical data can provide a testing ground for elements of normative theory. Even though empirical research can inform many parts of bioethical inquiry, normative expertise is recommended to guide ERiB. The acceptability of ambitious objectives for ERiB boils down to finding firm ground for the integration of empirical facts in normative inquiry.
Collapse
Affiliation(s)
- Emilian Mihailov
- grid.5100.40000 0001 2322 497XFaculty of Philosophy, University of Bucharest, Bucharest, Romania
| | - Veerle Provoost
- grid.5342.00000 0001 2069 7798Bioethics Institute Ghent, University of Ghent, Ghent, Belgium
| | - Tenzin Wangmo
- grid.6612.30000 0004 1937 0642Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| |
Collapse
|
12
|
Lo JJM, Graves N, Chee JH, Hildon ZJL. A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings. BMC Palliat Care 2022; 21:195. [DOI: 10.1186/s12904-022-01071-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 10/05/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.
Aim
To define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.
Design
Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.
Data sources
Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.
Results
Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.
Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.
Conclusion
A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.
Trial registration
PROSPERO Protocol CRD42021214137.
Collapse
|
13
|
Important End-of-Life Topics among Latino Patients and Caregivers Coping with Advanced Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158967. [PMID: 35897338 PMCID: PMC9330392 DOI: 10.3390/ijerph19158967] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
There is a known end-of-life related disparity among Latino individuals, and there is a need to develop culturally sensitive interventions to help patients and caregivers cope with advanced cancer. Latino patients and caregivers coping with advanced cancer were asked to list important end-of-life topics to culturally inform a psychosocial intervention adaptation process. A qualitative study was conducted, and semi-structured interviews were performed, audio-recorded, and transcribed. Recordings and transcriptions were reviewed and analyzed using thematic content coding. The semi-structured interview described and demonstrated intervention components and elicited feedback about each. Free listing method was used to assess important topics among Latino advanced cancer patients (n = 14; stage III and IV) and caregivers. Patients and caregivers were given a list of 15 topics and asked which topics they deemed important to integrate into the intervention. Overall, more than half of the participants considered it important to include 13 of the 15 topics related to daily activities (eight subcategories), psychosocial support (three subcategories), discussing diagnosis and support (three subcategories), and financial difficulties (one subcategory). Patient-caregivers reported importance in most end-of-life topics. Future research and intervention development should include topics related to psychosocial support, daily activities, discussing diagnosis and support, and financial difficulties.
Collapse
|
14
|
Rosa WE, Banerjee SC, Maingi S. Family caregiver inclusion is not a level playing field: toward equity for the chosen families of sexual and gender minority patients. Palliat Care Soc Pract 2022; 16:26323524221092459. [PMID: 35462621 PMCID: PMC9021511 DOI: 10.1177/26323524221092459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- William E. Rosa
- Assistant Attending Behavioral Scientist, Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Avenue, 7th fl., New York, NY 10022, USA
| | - Smita C. Banerjee
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shail Maingi
- Dana-Farber, South Shore Hospital, South Weymouth, MA, USA
| |
Collapse
|
15
|
Kieler M, Kössler P, Milovic M, Meyer E, Križanová K, Kum L, Friedrich A, Masel E, Bauer R, Unseld M. C-reactive protein and white blood cell count are adverse prognostic markers for patients with advanced cancer on parenteral nutrition in a palliative care unit setting: A retrospective cohort study. Palliat Med 2022; 36:540-548. [PMID: 35184630 PMCID: PMC8972954 DOI: 10.1177/02692163211073939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Parenteral nutrition is controversial in patients with advanced cancer. Nevertheless, this treatment is common practice near the end of life. AIM We aimed to identify factors which were associated with the outcome of patients on parenteral nutrition at an academic tertiary palliative care unit. DESIGN In this retrospective cohort study patients were assigned to two groups according to parenteral nutrition treatment. Inferential statistics were used to assess whether the dynamics of laboratory variables over 2 weeks of parenteral nutrition were associated with survival. SETTING/PARTICIPANTS Patients admitted to the Department of Palliative Medicine at the Medical University of Vienna between 2016 and 2018 were included in this study. RESULTS Of 443 patients, 113 patients received parenteral nutrition. Patients had a lower body mass index, lower levels of bilirubin, γ-glutamyltransferase, alkaline phosphatase, and were of younger age compared to patients which did not receive parenteral nutrition. No difference in survival as measured from admission to death was found when comparing the two groups. Levels for γ-glutamyltransferase, alkaline phosphatase, and C-reactive protein significantly increased during 2 weeks of parenteral nutrition. Among patients with parenteral nutrition, an increase in C-reactive protein or white blood cell count levels was associated with lower survival. CONCLUSION Patients who responded with an increase of C-reactive protein or white blood cell count during 2 weeks after reinitiation or start of parenteral nutrition had a worse survival. Our findings might support clinicians and patients in their decision to forgo parenteral nutrition in a palliative care setting.
Collapse
Affiliation(s)
- Markus Kieler
- Center for Physiology and Pharmacology, Institute for Vascular Biology, Medical University Vienna, Vienna, Austria
| | - Paul Kössler
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Matija Milovic
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Elias Meyer
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Kristína Križanová
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Lea Kum
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander Friedrich
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Eva Masel
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| | - Raimund Bauer
- Center for Pathobiochemistry and Genetics, Institute of Medical Chemistry and Pathobiochemistry, Medical University of Vienna, Vienna, Austria
| | - Matthias Unseld
- Department of Medicine I, Division of Palliative Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
16
|
Okamoto S, Uneno Y, Kawashima N, Oyamada S, Hiratsuka Y, Tagami K, Muto M, Morita T. Difficulties Facing Junior Physicians and Solutions Toward Delivering End-of-Life Care for Patients with Cancer: A Nationwide Survey in Japan. Palliat Med Rep 2022; 3:255-263. [PMID: 36341469 PMCID: PMC9629909 DOI: 10.1089/pmr.2022.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Junior physicians' perceived difficulty in end-of-life care of patients with cancer has not been structurally investigated; therefore, current challenges and solutions in this area remain unknown. OBJECTIVES To identify some difficulties junior physicians face in delivering end-of-life care for patients with cancer and to clarify the support required to reduce these difficulties. DESIGN A nationwide survey was conducted in over 300 institutions selected randomly from 1037 clinical training hospitals in Japan. PARTICIPANTS From each of these institutions, two resident physicians of postgraduate year (PGY) 1 or 2, two clinical fellows of PGY 3-5, and an attending physician were requested to respond to the survey. MEASUREMENTS The survey investigated issues regarding end-of-life care using the palliative care difficulties scale with two additional domains ("discussion about end-of-life care" and "death pronouncement"). Items related to potential solutions for alleviating the difficulties as well were investigated. RESULTS A total of 198 resident physicians, 134 clinical fellows, and 96 attending physicians responded to the survey (response rate: 33.0%, 22.3%, and 32.0%). The results revealed that junior physicians face difficulties within specific domains of end-of-life care. The most challenging domain comprised communication and end-of-life discussion with patients and family members, symptom alleviation, and death pronouncement. The most favored supportive measure for alleviating these difficulties was mentorship, rather than educational opportunities or resources regarding end-of-life care. CONCLUSION The findings of this study reveal the need for further effort to enrich the mentorship and support systems for junior physicians delivering end-of-life care.
Collapse
Affiliation(s)
- Soichiro Okamoto
- Medical Corporation Teieikai Chiba Home Care Clinic, Chiba, Japan
| | - Yu Uneno
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- *Address correspondence to: Yu Uneno, MD, Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan.
| | - Natsuki Kawashima
- Department of Palliative Care, Tsukuba Medical Center, Tsukuba, Japan
| | | | - Yusuke Hiratsuka
- Department of Palliative Care, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Keita Tagami
- Department of Palliative Care, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuya Morita
- Division of Supportive and Palliative Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| |
Collapse
|