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Wang H, Cheng M, Zhang Z, He X, Hu L, Yang D, Gong N. The ideal path to a good death: An international meta-synthesis of rural residents' perspectives. Palliat Med 2024:2692163241277928. [PMID: 39318112 DOI: 10.1177/02692163241277928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
BACKGROUND Rural areas frequently encounter restricted access to healthcare and end-of-life services. Given current pressing realities, understanding their unique perspectives on what constitutes a good death is essential. Existing research has largely overlooked the voices of rural residents. AIM To obtain a more comprehensive understanding of rural residents' expectations regarding a good death. DESIGN A meta-synthesis. By exploring the logic within relevant content, the stages of the life course serve as the framework for integration. DATA SOURCES PubMed, Web of Science Core Collection, Embase, Cochrane Library, CINAHL (EBSCO), PsycINFO (EBSCO), China National Knowledge Infrastructure (CNKI), WanFang, and China Biology Medicine disc (CBM) were systematically searched from their inception to May 2023. RESULT Of the 1100 articles retrieved, 8 studies were included. This paper outlines "the path to a rural good death": (1) When death is perceived as distant: acknowledge its inevitability while striving to achieve a successful and complete life journey. (2) As death approaches: maintain composure and have the capacity and support to face it. (3) When death truly arrives: depart in an envisioned scenario. (4) What's left behind: be properly arranged. CONCLUSION The essential characteristics of a rural good death align with previous interpretations. However, distinct aspects emerge: communities play a significant role, characterized by reciprocal relationships; the role of medicine is less emphasized; and "rurality" deeply shapes residents' expectations of a good death. The pathway to a good death presented in this article is aspirational, requiring collaborative efforts to make it a tangible reality.
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Affiliation(s)
- Huan Wang
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
| | - Meijing Cheng
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
| | - Ziqing Zhang
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
| | - Xiaoyu He
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
| | - Lei Hu
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
- Medical College, Chengdu Polytechnic/Chengdu Vocational and Technical College, Chengdu, Sichuan, P.R. China
| | - Dan Yang
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
- Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Ni Gong
- School of Nursing, Jinan University, Guangzhou, Guangdong, P.R. China
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Mah K, Namisango E, Luyirika E, Ntizimira C, Hales S, Zimmermann C, Malfitano C, Tilly A, Wolofsky K, Rodin G. Quality of Dying and Death of Patients With Cancer in Hospice Care in Uganda. JCO Glob Oncol 2023; 9:e2200386. [PMID: 36763934 PMCID: PMC10166526 DOI: 10.1200/go.22.00386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
PURPOSE Despite advances in palliative care in Uganda, there has been relatively little recent patient-centered research investigating end-of-life outcomes in this region. We assessed the quality of dying and death of patients with cancer in hospice care in Uganda. METHODS Bereaved caregivers of patients who received hospice care in Uganda and died 2-12 months earlier (N = 201) completed the Quality of Dying and Death Questionnaire, which includes 31 items and single-item ratings of overall quality of dying and moment of death, and the FAMCARE measure of family satisfaction with cancer care. RESULTS Caregivers reported low-intermediate overall quality of dying (mean [M] standard deviation [SD], 3.25 [2.98]) and overall quality of moment of death (M [SD], 3.59 [3.51]), with 47.0% of the ratings of these two outcomes in the poor range, but the mean family satisfaction with care was high (M [SD], 77.75 [10.26]). Most Quality of Dying and Death Questionnaire items (74.2%) were rated within the intermediate range. Items rated within the good range were religious-spiritual, interpersonal, and personal facets; two items within the poor range reflected physical functioning. Overall quality of dying was most strongly correlated with pain control (Spearman's rho [rs] = 0.45, P < .001), and overall quality of moment of death with state of consciousness before death and being unafraid of dying (rs = 0.42, P < .001). The FAMCARE score was not correlated with overall quality of dying or moment of death (P = .576-.813). Only one FAMCARE item, information on managing patient's pain, was correlated with overall quality of moment of death (rs = -0.19, P = .008). CONCLUSION End-of-life care in hospices in Uganda requires further improvement, particularly with regard to symptom control. Patient-centered data could bolster advocacy efforts to support quality improvement of palliative care in this and other countries.
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Affiliation(s)
- Kenneth Mah
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda.,Cicely Saunders Institute, King's College London, London, United Kingdom
| | | | | | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
| | - Carmine Malfitano
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Alyssa Tilly
- Division of General Medicine and Clinical Epidemiology and Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kayla Wolofsky
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Division of Palliative Care, University Health Network, Toronto, Ontario, Canada.,Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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Moss RH, Hussain J, Islam S, Small N, Dickerson J. Applying the community readiness model to identify and address inequity in end-of-life care in South Asian communities. Palliat Med 2022; 37:567-574. [PMID: 36579846 PMCID: PMC10074746 DOI: 10.1177/02692163221146587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Individuals from minoritised ethnic backgrounds are less likely than individuals from the dominant ethnic group to access palliative care services and to have documented Advance Care Plans. They are more likely to be admitted to hospital in the last months of life. AIM To use the Community Readiness Model to identify the barriers that influence how South Asian communities access and use two new palliative care services. DESIGN The Community Readiness Model is a validated tool that measures the readiness of a community. Key stakeholders were asked to: (i) complete a questionnaire to assess South Asian communities' readiness to engage in advance care planning and, (ii) attend a focus group to explore their views on the communities' understandings of palliative and end-of-life care. SETTING/PARTICIPANTS Ten key stakeholders who held a variety of occupations within palliative and end-of-life care services were recruited from the community. FINDINGS The South Asian communities were found to be at the 'pre-planning' stage of readiness, despite initiatives to improve awareness. The readiness of the health system was found to be limited, with a narrow medical focus during advance care planning, poor integration of voluntary and community services and limited understanding of what people consider a 'good' death. CONCLUSIONS The Community Readiness Model allowed insight into the South Asian communities' awareness of and readiness (to use) palliative care services. Using the Community Readiness Model before service implementation allowed steps to be taken to avoid widening inequities in access and use of new services.
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Affiliation(s)
- Rachael H Moss
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Jamilla Hussain
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK.,Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Shahid Islam
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Neil Small
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Josie Dickerson
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
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Meng X, An Z, Xu Y, Du J, Tan L, Yu H, Yu L. Living experiences of people with advance cancer with low socioeconomic status: A systematic review of qualitative evidence. Palliat Med 2022; 37:444-459. [PMID: 36411513 DOI: 10.1177/02692163221137106] [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] [Indexed: 11/23/2022]
Abstract
BACKGROUND The number of patients with advanced cancer is rapidly increasing, and the subgroup of this population with low socioeconomic status has suffered more disease burden than others. However, there is no recent qualitative synthesis of primary research studies into advanced cancer patients with low socioeconomic status. OBJECTIVE To synthesise qualitative research findings into advanced cancer patients' experiences with low socioeconomic status, and then to help provide targeted and effective strategies to improve their quality of life. DESIGN A systematic review and meta-synthesis of qualitative evidence (PROSPERO: CRD42021250423). DATA SOURCES PubMed, Web of Science Core Collection (ISI Web of Science), Cochrane Library, Embase, OVID LWW, CINAHL Complete (EBSCO), PsycINFO (EBSCO) and MEDLINE (ISI Web of Science), China National Knowledge Infrastructure (CNKI), WangFang, and Vip databases were systematically searched from their original dates to July 2022. Qualitative data were appraised using the Joanna Briggs Institute (JBI) qualitative assessment. FINDINGS The findings were synthesised into the following three analytical themes: (1) multi-dimensional disease distresses; (2) barriers in coping with disease distresses; and (3) strategies for dealing with disease distresses. CONCLUSIONS Patients with advanced cancer with low socioeconomic status experienced complicated and interactional distresses, unique life barriers, and a wide range of adaptation strategies. These findings will provide a comprehensive perspective to promote individual-centred health care systems and services to help these vulnerable people deal with the challenges of disease and improve their quality of life.
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Affiliation(s)
- Xianmei Meng
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Zifen An
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Yuying Xu
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Jiayi Du
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Lanhui Tan
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Huidan Yu
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
| | - Liping Yu
- Center for Nurturing Care Research, School of Nursing, Wuhan University, No. 115 Donghu Road, Wuhan, Hubei, China
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Hogan U, Bingley A, Morbey H, Walshe C. The experience of informal caregivers in providing patient care in hospitals in low- and middle-income countries: A qualitative meta-synthesis. J Health Serv Res Policy 2022; 27:321-329. [PMID: 35592881 PMCID: PMC9548935 DOI: 10.1177/13558196221101968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In low- and middle-income countries, informal caregivers frequently stay in hospitals and perform patient care tasks typically performed by nurses in other contexts. This article reviews qualitative research on these informal caregivers, to gain insight and understanding of their experiences. METHODS We undertook a qualitative meta-synthesis. Relevant literature was identified through searches of electronic databases in 2021. Thematic analysis was conducted to facilitate the identification of conceptual relationships to formulate synthesised findings. RESULTS Twenty-four studies met the inclusion criteria - 13 from Sub-Saharan Africa, five from Bangladesh, two from India, two from Iran, one from Brazil and one from Peru. Three themes were generated from the meta-synthesis: (1) The unwelcome but tolerated guest, (2) Enduring personal sacrifice and (3) Fulfilling familial obligations. These themes emphasised the significant burden associated with the hospital caregiving experience and highlighted the implicit reliance on informal caregivers in low- and middle-income countries. CONCLUSIONS Informal caregivers perform an essential caregiving role, yet occupy a peripheral and voluntary space in hospitals. There is a clear need to support informal caregivers so that they can safely perform their tasks.
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Affiliation(s)
- Unarose Hogan
- Division of Health Research, Faculty of Health and Medicine, 151268Lancaster University, Bailrigg, UK
| | - Amanda Bingley
- Division of Health Research, Faculty of Health and Medicine, 151268Lancaster University, Bailrigg, UK
| | - Hazel Morbey
- Division of Health Research, Faculty of Health and Medicine, 151268Lancaster University, Bailrigg, UK
| | - Catherine Walshe
- Division of Health Research, Faculty of Health and Medicine, 151268Lancaster University, Bailrigg, UK
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Silverstein A, Butia M, Bank R, Manda G, Nyasulu C, Mwango N, Makuti S, Chikasema M, Torrey S, Hesselgrave J, Casas J, Thambo L, Msekandiana A, Chiume M, Ozuah N, Huibers MH. Palliative Care Services within a Pediatric Hematology-Oncology Program in a Low-Resource Setting. J Pain Symptom Manage 2022; 63:e473-e480. [PMID: 35031502 DOI: 10.1016/j.jpainsymman.2022.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Outcomes for children with cancer in sub-Saharan Africa (SAA) are dismal due to delayed diagnosis and limited access to curative therapy. When establishing a pediatric hematology-oncology (PHO) program in low-resource settings, early integration of palliative care services becomes essential. While palliative care is a human right, equitable distribution is lacking. OBJECTIVES We aim to describe our experience establishing a palliative care program, the services offered, and the distribution of patients served. METHODS This is a brief description of our PHO palliative care program in Lilongwe, Malawi at a tertiary care center and a three-year retrospective review of activities (2017-2020). Services offered include inpatient, outpatient, home visits, end of life care, and strengthening of referral systems. RESULTS Over the three-year period, 315 patients were enrolled. 57% (n=179) were male. The median age was seven years (5 months-22 years). Patients served were from 17 of 28 districts within Malawi. Diagnoses of patients included 43% solid tumors (n=135), 22% lymphoma (n=68), 15% leukemia (n=47), and 21% hematologic disease (n=65). 40% of patients have died (n=125), with 53% of deaths occurring at home (n=66), 22% in the hospital (n=28), and 25% at unknown locations (n=31). CONCLUSION Palliative care is a critical component of PHO programs worldwide. Programs must leverage existing networks to ensure optimal care to children and families. We demonstrate the feasibility of integrating palliative care services within a PHO program in a low-resource setting, which could serve as a model for other countries in SSA.
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Affiliation(s)
- Allison Silverstein
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA.
| | - Mercy Butia
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Rhahim Bank
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Geoffrey Manda
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Constance Nyasulu
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Noel Mwango
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Samuel Makuti
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Maria Chikasema
- University of North Carolina Project-Malawi (M.C.), Lilongwe, Malawi
| | - Susan Torrey
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA
| | - Joy Hesselgrave
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA
| | - Jessica Casas
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA
| | - Lameck Thambo
- Palliative Care Association of Malawi (L.T.), Lilongwe, Malawi
| | - Amos Msekandiana
- Department of Pediatrics (A.M., M.C.), Kamuzu Central Hospital, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics (A.M., M.C.), Kamuzu Central Hospital, Lilongwe, Malawi
| | - Nmazuo Ozuah
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA; Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Minke Hw Huibers
- Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (A.S., S.T., J.H., J.C., N.O., M.H.H.), Texas Children's Hospital, Houston, Texas, USA; Department of Pediatrics (A.S., S.T., J.H., J.C., N.O., M.H.H.), Baylor College of Medicine, Houston, Texas USA; Global HOPE (Hematology-Oncology-Pediatric-Excellence) Program (M.B., R.B., G.M., C.N., N.M., S.M., N.O., M.H.H.), Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
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Uwayezu MG, Nikuze B, Maree JE, Buswell L, Fitch MI. Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action. JCO Glob Oncol 2022; 8:e2100240. [PMID: 35044834 PMCID: PMC8789211 DOI: 10.1200/go.21.00240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/19/2021] [Accepted: 12/17/2021] [Indexed: 12/28/2022] Open
Abstract
Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.
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Affiliation(s)
- Marie Goretti Uwayezu
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Bellancille Nikuze
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Johanna E. Maree
- Department of Nursing Education, University of the Witwatersrand, Johannesburg & Netcare Education, Johannesburg, South Africa
| | - Lori Buswell
- Dana-Farber Cancer Institute, Boston, MA
- Partners in Health, Boston, MA
| | - Margaret I. Fitch
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Rory Meyer's College of Nursing, New York University, New York, NY
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Pedroso-Chaparro MDS, Márquez-González M, Vara-García C, Cabrera I, Romero-Moreno R, Barrera-Caballero S, Losada A. Guilt for perceiving oneself as a burden in healthy older adults. Associated factors. Aging Ment Health 2021; 25:2330-2336. [PMID: 32964745 DOI: 10.1080/13607863.2020.1822291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
METHODS Participants were 317 community-dwelling people over 60 years without cognitive or functional limitations. A path model that explores the role of self-perceived burden in the relationship between negative self-perception of aging, perceived control, depressive symptoms and guilt associated with self-perception as a burden was analyzed. RESULTS The model presented excellent fit to the data, explaining 41% of the depressive symptomatology and 45% of guilt for perceiving oneself as a burden. Negative self-perceptions of aging, lower sense of control, and a perception of being a burden were significantly associated with depressive symptoms and guilt for perceiving oneself as a burden. DISCUSSION This study documents potential correlates of psychological distress in older adults with no explicit physical or cognitive problems, suggesting paths through which feelings of guilt for perceiving oneself as a burden may be reported by this population.
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Affiliation(s)
| | - María Márquez-González
- Department de Biological and Health Psychology, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Isabel Cabrera
- Department de Biological and Health Psychology, Universidad Autónoma de Madrid, Madrid, Spain
| | | | | | - Andrés Losada
- Department of Psychology, Universidad Rey Juan Carlos, Alcorcón, Spain
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9
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Nalugya LG, Harborne D, Reid E. Factors affecting initiation of palliative care in a Ugandan Emergency Department. Afr J Emerg Med 2021; 11:442-446. [PMID: 34765429 PMCID: PMC8568603 DOI: 10.1016/j.afjem.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/30/2021] [Accepted: 06/04/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The Emergency Department (ED) of Mbarara Regional Referral Hospital serves a largely rural population of 4 million people in western Uganda. Here, ED patients with incurable illness often have prolonged stays. Palliative care (PC) is a low-cost intervention that focuses on alleviating pain and suffering for patients with incurable disease, while improving satisfaction with care and optimizing healthcare utilization. This is especially important in low resource settings. A prior needs assessment in our ED revealed that 50% of patients have PC needs. The ED is an optimal location to initiate PC, yet this rarely happens. There is a great need to identify factors affecting initiation of ED PC in our resource-limited setting. Methods A semi-structured questionnaire and chart review was conducted from March to August 2020. Patients admitted from the ED were assessed for PC needs. Those who met criteria were approached for inclusion and flagged for initiation of PC. The follow-up period was 7 days. Results Sixty two percent of those subjects flagged for initiation of PC received it. By day seven, 36.1 of the study population had died. ED initiation of PC varied significantly by diagnosis, with cancer patients more likely to receive PC (p = 0.0097). Conclusion Important barriers to PC initiation were identified in our Ugandan ED, related to diagnosis. These barriers could be overcome by improving awareness of PC amongst patients and providers alike and implementing a PC screening tool for all admissions. Future research is needed to identify other barriers, as well as strategies for improved hospital-wide uptake of PC in this resource-limited setting.
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Afolabi OA, Nkhoma K, Maddocks M, Harding R. What constitutes a palliative care need in people with serious illnesses across Africa? A mixed-methods systematic review of the concept and evidence. Palliat Med 2021; 35:1052-1070. [PMID: 33860715 PMCID: PMC8371282 DOI: 10.1177/02692163211008784] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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 Clarity on what constitutes a palliative care need is essential to ensure that health systems and clinical services deliver an appropriate response within Universal Health Coverage. AIM To synthesise primary evidence from Africa for palliative care needs among patients and families with serious illness. DESIGN We conducted a mixed methods systematic review with sequential synthesis design. The protocol was registered with PROSPERO (CRD42019136606) and included studies were quality assessed using Mixed Method Appraisal Tool. DATA SOURCES Six global literature databases and Three Africa-specific databases were searched up to October 2020 for terms related to palliative care, serious illnesses and Africa. Palliative care need was defined as multidimensional problems, symptoms, distress and concerns which can benefit from palliative care. RESULTS Of 7810 papers screened, 159 papers met eligibility criteria. Palliative care needs were mostly described amongst patients with HIV/AIDS (n = 99 studies) or cancer (n = 59), from East (n = 72) and Southern (n = 89) Africa. Context-specific palliative care needs included managing pregnancy and breastfeeding, preventing infection transmission (physical); health literacy needs, worry about medical bills (psychological); isolation and stigma, overwhelmed families needing a break, struggling to pay children's school fees and selling assets (social and practical needs); and rites associated with cultural and religious beliefs (spiritual). CONCLUSIONS Palliative care assessment and care must reflect the context-driven specific needs of patients and families in Africa, in line with the novel framework. Health literacy is a crucial need in this context that must be met to ensure that the benefits of palliative care can be achieved at the patient-level.
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Affiliation(s)
- Oladayo A Afolabi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Department of Nursing Science, University of Maiduguri, Maiduguri, Nigeria
| | - Kennedy Nkhoma
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Kaba M, de Fouw M, Deribe KS, Abathun E, Peters AAW, Beltman JJ. Palliative care needs and preferences of female patients and their caregivers in Ethiopia: A rapid program evaluation in Addis Ababa and Sidama zone. PLoS One 2021; 16:e0248738. [PMID: 33886561 PMCID: PMC8062072 DOI: 10.1371/journal.pone.0248738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 03/04/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION In Ethiopia there is an extensive unmet need for palliative care, while the burden of non-communicable diseases and cancer is increasing. This study aimed to explore palliative care needs and preferences of patients, their caregivers, and the perspective of stakeholders on service provision in palliative programs for women, mostly affected by cervical cancer and breast cancer. METHODS A rapid program evaluation using a qualitative study approach was conducted in three home-based palliative care programs in Addis Ababa and Yirgalem town, Ethiopia. Female patients enrolled in the programs, and their primary caregivers were interviewed on palliative care needs, preferences and service provision. We explored the views of purposely selected stakeholders on the organization of palliative care and its challenges. Audio-taped data was transcribed verbatim and translated into English and an inductive thematic analysis was applied. Descriptive analyses were used to label physical signs and symptoms using palliative outcome scale score. RESULTS A total of 77 interviews (34 patients, 12 primary caregivers, 15 voluntary caregivers, 16 stakeholders) were conducted. The main physical complaints were moderate to severe pain (70.6%), followed by anorexia (50.0%), insomnia, nausea and vomiting (41.2%). Social interaction and daily activities were hampered by the patients' condition. Both patients and caregivers reported that programs focus most on treatment of symptoms, with limited psychosocial, emotional, spiritual and economic support. Lack of organizational structures and policy directions limit the collaboration between stakeholders and the availability of holistic home-based palliative care services. CONCLUSIONS Although female patients and caregivers appreciated the palliative care and support provided, the existing services did not cover all needs. Pain management and all other needed supports were lacking. Multi-sectorial collaboration with active involvement of community-based structures is needed to improve quality of care and access to holistic palliative care services.
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Affiliation(s)
- Mirgissa Kaba
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail: (MK); (KSD)
| | - Marlieke de Fouw
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kalkidan Solomon Deribe
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail: (MK); (KSD)
| | | | | | - Jogchum Jan Beltman
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
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Validation of the Guilt associated with Self-Perception as a Burden Scale (G-SPBS). Behav Cogn Psychother 2020; 49:185-196. [PMID: 32829723 DOI: 10.1017/s1352465820000557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND One of the main health-related worries for older adults is becoming dependent. Even healthy older adults may worry about becoming dependent, generating guilt feelings due to the anticipation of future needs that others must solve. The guilt associated with self-perception as a burden has not been studied in older adults, and there is no instrument available to measure these feelings. AIMS To adapt the Self-Perceived Burden Scale (SPBS; Cousineau et al., 2003) for the assessment of feelings of guilt for perceiving oneself as a burden for the family in older adults without explicit functional or cognitive impairment. METHOD Participants were 298 older adults living independently in the community. Participants completed the assessment protocol, which included measures of guilt associated with self-perception as a burden, depressive and anxious symptomatology, self-perceived burden, and sociodemographic information. RESULTS Results from exploratory, parallel and confirmatory factor analyses suggest that the scale, named Guilt associated with Self-Perception as a Burden Scale (G-SPBS), has a unidimensional structure, explaining 57.04% of the variance of guilt. Good reliability was found (Cronbach's alpha = .94). The results revealed significant (p < .01) positive associations with depressive and anxious symptomatology. DISCUSSION These findings suggest that the G-SPBS shows good psychometric properties which endorse its use with healthy community older adults. Also, guilt associated with perceiving oneself as a burden seems to be a relevant variable that can contribute to improving our understanding of psychological distress in older adults.
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Gafaar TO, Pesambili M, Henke O, Vissoci JRN, Mmbaga BT, Staton C. Good death: An exploratory study on perceptions and attitudes of patients, relatives, and healthcare providers, in northern Tanzania. PLoS One 2020; 15:e0233494. [PMID: 32649715 PMCID: PMC7351142 DOI: 10.1371/journal.pone.0233494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 05/06/2020] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE In the Kilimanjaro region of Tanzania, there are no advance care planning (ACP) protocols being used to document patient preferences for end-of-life (EoL) care. There is a general avoidance of the topic and contemplating ACP in healthcare-limited regions can be an ethically complex subject. Nonetheless, evidence from similar settings indicate that an appropriate quality of life is valued, even as one is dying. What differs amongst cultures is the definition of a 'good death'. OBJECTIVE Evaluate perceptions of quality of death and advance EoL preparation in Moshi, Tanzania. DESIGN 13 focus group discussions (FGDs) were conducted in Swahili using a semi-structured guide. These discussions were audio-recorded, transcribed, translated, and coded using an inductive approach. SETTING Kilimanjaro Christian Medical Centre (KCMC), referral hospital for northern Tanzania. PARTICIPANTS A total of 122 participants, including patients with life-threatening illnesses (34), their relatives/friends (29), healthcare professionals (29; HCPs; doctors and nurses), and allied HCPs (30; community health workers, religious leaders, and social workers) from KCMC, or nearby within Moshi, participated in this study. FINDINGS In characterizing Good Death, 7 first-order themes emerged, and, of these themes, Religious & Spiritual Wellness, Family & Interpersonal Wellness, Grief Coping & Emotional Wellness, and Optimal Timing comprised the second-order theme, EoL Preparation and Life Completion. The other first-order themes for Good Death were Minimal Suffering & Burden, Quality of Care by Formal Caregivers, and Quality of Care by Informal Caregivers. INTERPRETATION The results of this study provide a robust thematic description of Good Death in northern Tanzania and they lay the groundwork for future clinical and research endeavors to improve the quality of EoL care at KCMC.
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Affiliation(s)
- Temitope O. Gafaar
- Duke University School of Medicine, Duke University, Durham, NC, United States of America
| | - Msafiri Pesambili
- Duke University Research Collaboration, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Oliver Henke
- Cancer Care Center, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
| | - Blandina Theophil Mmbaga
- Cancer Care Center, Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine Staton
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC, United States of America
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Krikorian A, Maldonado C, Pastrana T. Patient's Perspectives on the Notion of a Good Death: A Systematic Review of the Literature. J Pain Symptom Manage 2020; 59:152-164. [PMID: 31404643 DOI: 10.1016/j.jpainsymman.2019.07.033] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/26/2019] [Accepted: 07/26/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT There is no clear definition of what constitutes a good death or its features. Patients, caregivers, physicians, and relatives have different notions of a good death. Discussions have been driven by academic perspectives, with little research available on the patients' perspectives. OBJECTIVES To explore the notions of a good death from the patients' perspective. METHODS A systematic literature search was conducted up to November 2017 using CINAHL®, MEDLINE®, EMBASE®, and PsycINFO® databases. Search terms used were "quality of death," "good death," "quality of dying," or "good dying." Scientific empirical studies that included the exploration of the notion of a good death in adult patients with advanced and life-threatening diseases were selected separately by two researchers. Hawker's et al. criteria were used to assess the quality of articles. The analysis was conducted using a thematic analysis. RESULTS Two thousand six hundred and fifty two titles were identified; after elimination of duplicates, screening, and final selection, 29 relevant publications remained for analysis. Sample populations included patients with terminal diseases (AIDS, cardiovascular disease, and cancer). Core elements for a "good death" included control of pain and symptoms, clear decision-making, feeling of closure, being seen and perceived as a person, preparation for death, and being still able to give something to others; whereas other factors such as culture, financial issues, religion, disease, age, and life circumstances were found to shape the concept across groups. Studies agree on the individuality of death and dying while revealing a diverse set of preferences, regarding not only particular attributes but also specific ways in which they contribute to a good death. CONCLUSIONS Although sharing common core elements, patients' notions of good death are individual, unique, and different. They are dynamic in nature, fluctuating within particular groups and during the actual process of dying. Formal and informal caregivers should carefully follow-up and respect the patient's individual concepts and preferences regarding death and dying, while attending to shared core elements, to better adjust clinical decisions.
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Affiliation(s)
- Alicia Krikorian
- Group of Pain and Palliative Care, School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Colombia.
| | - Camilo Maldonado
- Faculty of Medicine, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Tania Pastrana
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
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Mendenhall E, Rinehart R, Musyimi C, Bosire E, Ndetei D, Mutiso V. An ethnopsychology of idioms of distress in urban Kenya. Transcult Psychiatry 2019; 56:620-642. [PMID: 30672722 DOI: 10.1177/1363461518824431] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idioms of distress have become a central construct of anthropologists who aspire to understand the languages that individuals of certain sociocultural groups use to express suffering, pain, or illness. Yet, such idioms are never removed from global flows of ideas within biomedicine that influence how cultural idioms are conceived, understood, and expressed. This article proposes a preliminary model of ethnopsychology described by urban Kenyans, which incorporates local (traditional) and global (biomedical) idioms of distress that are both distinct and overlapping in symptomology and experience. This ethnopsychology was generated from analyzing 100 life history narrative interviews among patients seeking care in a public hospital in Nairobi, Kenya, which explicitly probed into how people experienced and expressed the Kiswahili idioms huzuni (roughly translated as sadness or grief) and dhiki (stress or agony) and English terms stress and depression. Kufikiria sana, or "thinking too much", emerged organically as a powerful cultural idiom and as a symptom or sign of other forms of psychological distress. We propose a preliminary model of ethnopsychology that: 1) highlights social and political factors in driving people to express and experience idioms of distress; 2) reveals how the English terms "stress" and "depression" have been adopted into Kiswahili discourse and potentially have taken on new meaning; 3) suggests that the role of rumination in how people express distress, with increasing severity, is closely linked to the concept of "thinking too much", and; 4) emphasizes how somatization is central to how people think about psychological suffering.
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Affiliation(s)
| | | | | | | | - David Ndetei
- Africa Mental Health Foundation and University of Nairobi
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Seidel S, Muciimi J, Chang J, Gitari S, Keiser P, Goodman ML. Community perceptions of home environments that lead children & youth to the street in semi-rural Kenya. CHILD ABUSE & NEGLECT 2018; 82:34-44. [PMID: 29852364 DOI: 10.1016/j.chiabu.2018.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/04/2018] [Accepted: 05/10/2018] [Indexed: 06/08/2023]
Abstract
Research with street-involved children and youth (SICY) in Sub-Saharan Africa over the past three decades has established a complex web of both micro and macro-level factors that simultaneously "push" and "pull" children and youth to the street. There is still little research with adult family and community members in communities from which SICY originate. Forty men and women from five semi-rural villages in Meru County, Kenya participated in a Rapid Rural Appraisal utilizing a fishbone diagram to explore main and underlying reasons for why children may be or may feel unwelcome in the home and thus migrate to the street. Responses were analyzed in terms of ecological levels, child or parent perspective, and the push/pull framework. Overall, community members identified families and households experiencing stress and lacking the necessary resources to successfully adjust and adapt. Four ecological levels of influence were proposed as main reasons, with parent and caregiver factors mentioned most often, followed by household factors, children's intrapersonal factors, and interpersonal (family) factors. Community and environmental level factors were also proposed as underlying factors. Analysis by gender revealed that both men and women emphasized push factors over pull factors, though men proposed more pull factors (from peers and street life) than women did. Men placed more responsibility on the children than women did, citing children's negative behaviors, dissatisfaction with home, and a desire for independence and work/income. Women, in contrast, emphasized children's feelings of being unloved and the experience of harsh punishment or abuse from caregivers. Findings suggest that interventions to reduce street involvement should support economically, medically, and psychologically vulnerable families and households through comprehensive family strengthening programs that build financial capacity, improve parenting and communication skills, and promote education over child work and labor.
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Affiliation(s)
- Sarah Seidel
- University of Texas School of Public Health, Austin, TX 78701, United States; Sodzo International, OVC Research Division, 4100 South Main, Houston, TX 77002, United States.
| | | | - James Chang
- University of Texas Medical Branch, Galveston, TX 77551, United States
| | | | - Philip Keiser
- University of Texas Medical Branch, Galveston, TX 77551, United States
| | - Michael L Goodman
- Sodzo International, OVC Research Division, 4100 South Main, Houston, TX 77002, United States; University of Texas Medical Branch, Galveston, TX 77551, United States
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Rainsford S, MacLeod RD, Glasgow NJ, Wilson DM, Phillips CB, Wiles RB. Rural residents' perspectives on the rural 'good death': a scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:273-294. [PMID: 27641713 DOI: 10.1111/hsc.12385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2016] [Indexed: 06/06/2023]
Abstract
The 'good death' is one objective of palliative care, with many 'good death' viewpoints and research findings reflecting the urban voice. Rural areas are distinct and need special consideration. This scoping review identified and charted current research knowledge on the 'good' rural death through the perspectives of rural residents, including rural patients with a life-limiting illness, to identify evidence and gaps in the literature for future studies. A comprehensive literature search of English language articles (no date filter applied) was conducted in 2016 (2 January to 14 February) using five library databases. Reference lists of included articles, recent issues of eight relevant journals and three grey literature databases were also hand-searched. Twenty articles (for 17 studies and one systematic review) were identified after a two-phase screening process by two reviewers, using pre-determined inclusion criteria. Data from each study were extracted and charted, analysed using a thematic analysis of the included articles' content, and with a quantitative analysis of the scoping review. These papers revealed data collected from rural patients with a life-limiting illness and family caregivers, rural healthcare providers, the wider rural community, rural community leaders and rural health administrators and policy makers. Rural locations were heterogeneous. Residents from developed and developing countries believe a 'good death' is one that is peaceful, free of pain and without suffering; however, this is subjective and priorities are based on personal, cultural, social and religious perspectives. Currently, there is insufficient data to generalise rural residents' perspectives and what it means for them to die well. Given the extreme importance of a 'good death', there is a need for further studies to elicit rural patient and family caregiver perspectives.
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Affiliation(s)
- Suzanne Rainsford
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Roderick D MacLeod
- HammondCare, Sydney, New South Wales, Australia
- Palliative Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas J Glasgow
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Christine B Phillips
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Robert B Wiles
- Rural Clinical School, Australian National University, Cooma, New South Wales, Australia
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18
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Young JR, Sih C, Hogg MM, Anderson-Montoya BL, Fasano HT. Qualitative Assessment of Face Validity and Cross-Cultural Acceptability of the Faces Pain Scale: "Revised" in Cameroon. QUALITATIVE HEALTH RESEARCH 2018; 28:832-843. [PMID: 29571279 DOI: 10.1177/1049732318757488] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The Faces Pain Scale-Revised (FPS-R) is a self-report pain scale validated in numerous countries, but not in Cameroon. We postulated that while cultural factors influence pain perception and expression, the FPS-R should remain culturally acceptable for pediatric use. A convenience sample of 36 pediatric patients, aged 4 to 16 years, representing three primary language groups, was enrolled at Mbingo Baptist Hospital (MBH). Pre- and postanalgesia FPS-R scores and vital signs were obtained. Audio-recorded cognitive interviews were performed with each participant. Written questionnaires were also provided to physicians, nurses, and caretakers to further explore cultural perceptions of pain. Four independent reviewers analyzed interview transcripts and questionnaires using inductive reasoning and identified common themes pertaining to gender differences, societal roles, and pain perception. Basic comprehension of the FPS-R was present across language groups, vital sign changes corresponded with FPS-R alterations, and the FPS-R appears intuitive for pediatric use.
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Affiliation(s)
- James R Young
- 1 Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Colette Sih
- 2 Mbingo Baptist Hospital, Cameroon, West Africa
| | - Melanie M Hogg
- 1 Carolinas Medical Center, Charlotte, North Carolina, USA
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Reid EA, Gudina EK, Ayers N, Tigineh W, Azmera YM. Caring for Life-Limiting Illness in Ethiopia: A Mixed-Methods Assessment of Outpatient Palliative Care Needs. J Palliat Med 2018; 21:622-630. [PMID: 29425055 DOI: 10.1089/jpm.2017.0419] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Palliative care aims to reduce physical suffering and the emotional, spiritual, and psychosocial distress of life-limiting illness. Palliative care is a human right, yet there are vast disparities in its provision: of the 40 million people globally in need of palliative care, less than 10% receive it, largely in high-income countries. There is a particular paucity of data on palliative care needs across the spectrum of incurable disease in Ethiopia. OBJECTIVES The aims of this research were to assess the overall burden of life-limiting illness, the costs associated with life-limiting illness, and barriers to accessing palliative care in Ethiopia. DESIGN Mixed-methods case-series. SETTING/SUBJECTS One hundred adults (mean age: 43.7 ± 14 years, 64% female) were recruited at three outpatient clinics (oncology, HIV, noncommunicable disease) and hospice patient homes in Ethiopia. MEASUREMENTS Four internationally validated questionnaires were used to assess physical symptoms, psychosocial distress, and disability. In-depth interviews gauged poverty level, costs of care, and end-of-life preferences. Qualitative data were analyzed by thematic content, quantitative data by standard descriptive, frequency and regression analyses. RESULTS In oncology, 95.5% of the population endorsed moderate or severe pain, while 24% were not prescribed analgesia. Importantly, 80% of the noncommunicable disease population reported moderate or severe pain. The mean psychosocial distress score was 6.4/10. Severe disability was reported in 26% of the population, with mobility most affected. Statistically significant relationships were found between pain and costs, and pain and lack of well-being. Very high costs were reported by oncology patients. Oncology withstanding, the majority of subjects wished to die at home. Oncology patients cited pain control as the top reason they preferred a hospital death. CONCLUSION There are extensive unmet palliative care needs in Ethiopia. Untreated pain and high costs of illness are the major contributors to psychosocial distress and financial crisis in this Ethiopian population.
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Affiliation(s)
- Eleanor Anderson Reid
- 1 Section of Global Health and International Emergency Medicine, Department of Emergency Medicine, Yale University School of Medicine , New Haven, Connecticut
| | - Esayas Kebede Gudina
- 2 Department of Internal Medicine, Jimma University College of Health Sciences , Jimma, Ethiopia
| | - Nicola Ayers
- 3 Federal Ministry of Health , Addis Ababa, Ethiopia .,4 Hospice Ethiopia , Addis Ababa, Ethiopia
| | - Wondimagegnu Tigineh
- 5 Department of Oncology, Tikur Anbessa Hospital, Addis Ababa University College of Health Sciences , Addis Ababa, Ethiopia
| | - Yoseph Mamo Azmera
- 3 Federal Ministry of Health , Addis Ababa, Ethiopia .,4 Hospice Ethiopia , Addis Ababa, Ethiopia
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Mori M, Kuwama Y, Ashikaga T, Parsons HA, Miyashita M. Acculturation and Perceptions of a Good Death Among Japanese Americans and Japanese Living in the U.S. J Pain Symptom Manage 2018; 55:31-38. [PMID: 28842219 DOI: 10.1016/j.jpainsymman.2017.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 08/11/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
CONTEXT Acculturation is the phenomenon of the attitudinal changes of individuals who come into continuous contact with another culture. Despite the long history of Japanese immigration to America, little is known about the impact of acculturation on perceptions of a good death. OBJECTIVES To examine differences in perceptions of a good cancer death among Japanese Americans (JA/A), Japanese living in America (J/A), and the Japanese living in Japan (J/J). METHODS We administered surveys among JA/A and J/A and used historical J/J data for reference. Primary endpoint was the proportion of respondents who expressed the necessity of core and optional items of the Good Death Inventory. Group differences ≥20% were deemed clinically important. RESULTS In total, 441 survey responses in America and 2548 in Japan were obtained. More than 80% of respondents consistently considered nine of 10 core items necessary without significant group differences. No core item reached a ≥20% group difference. Three of the eight optional items reached ≥20% group difference: fighting against disease until one's last moment (49%, P < 0.0001; 52%, P < 0.0001; and 73% in JA/A, J/A, and J/J, respectively), knowing what to expect about one's condition in the future (83%, P < 0.0001; 80%, P < 0.0001; and 58%, respectively), and having faith (64%, P = 0.0548; 43%, P = 0.0127; and 38%, respectively). CONCLUSION Although most core items of a good death were preserved throughout the levels of acculturation, perceptions of some optional items shifted away from Japanese attitudes as individuals became more acculturated. Understanding of different levels of acculturation may help clinicians provide culturally sensitive end-of-life care.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Shizuoka, Japan.
| | - Yuichiro Kuwama
- Mount Sinai Beth Israel, Japanese Medical Practice, New York, New York
| | - Takamaru Ashikaga
- Department of Medical Biostatistics, University of Vermont College of Medicine, Burlington, Vermont
| | - Henrique A Parsons
- Department of Medicine/Division of Palliative Care, University of Ottawa, Ontario, Canada
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan
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Kimani KN, Namukwaya E, Grant L, Murray SA. Cancer and palliative care in Africa. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28111855 DOI: 10.1111/ecc.12655] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 11/28/2022]
Affiliation(s)
- K N Kimani
- Primary Palliative Care Research Group, The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Namukwaya
- Department of Medicine, Makerere Palliative Care Unit, Makerere University, Kampala, Uganda
| | - L Grant
- Primary Palliative Care Research Group, The Usher Institute, University of Edinburgh, Edinburgh, UK.,Global Health Academy, University of Edinburgh, Edinburgh, UK
| | - S A Murray
- Primary Palliative Care Research Group, The Usher Institute, University of Edinburgh, Edinburgh, UK
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Still Searching: A Meta-Synthesis of a Good Death from the Bereaved Family Member Perspective. Behav Sci (Basel) 2017; 7:bs7020025. [PMID: 28441339 PMCID: PMC5485455 DOI: 10.3390/bs7020025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/18/2017] [Accepted: 04/19/2017] [Indexed: 11/16/2022] Open
Abstract
The concept of a good death continues to receive attention in end-of-life (EOL) scholarship. We sought to continue this line of inquiry related to a good death by conducting a meta-synthesis of published qualitative research studies that examined a good death from the bereaved family member's perspective. Results of the meta-synthesis included 14 articles with 368 participants. Based on analysis, we present a conceptual model called The Opportunity Model for Presence during the EOL Process. The model is framed in socio-cultural factors, and major themes include EOL process engagement with categories of healthcare participants, communication and practical issues. The second theme, (dis)continuity of care, includes categories of place of care, knowledge of family member dying and moment of death. Both of these themes lead to perceptions of either a good or bad death, which influences the bereavement process. We argue the main contribution of the model is the ability to identify moments throughout the interaction where family members can be present to the EOL process. Recommendations for healthcare participants, including patients, family members and clinical care providers are offered to improve the quality of experience throughout the EOL process and limitations of the study are discussed.
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Githaiga JN. Culture, role conflict and caregiver stress: The lived experiences of family cancer caregivers in Nairobi. J Health Psychol 2016; 22:1591-1602. [PMID: 26895856 DOI: 10.1177/1359105316631199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This article explores the experiences of a small group of Nairobi women caring for a family cancer patient at home. On the basis of literature on women as caregivers in Africa, and on other literature more broadly, it was anticipated that issues around generational roles, gender and women's cultural role would be relevant. Seven women participated in semi-structured in-depth interviews, while thirteen women participated in four mini focus groups. Data were analysed using interpretative phenomenological analysis. Findings underscore the socio-cultural complexities of caregiving as a basis for evidence-based culturally appropriate structures to support family caregivers.
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Living with AIDS in Uganda: a qualitative study of patients' and families' experiences following referral to hospice. BMC Palliat Care 2015; 14:67. [PMID: 26615391 PMCID: PMC4662801 DOI: 10.1186/s12904-015-0066-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 11/25/2015] [Indexed: 11/10/2022] Open
Abstract
Background Globally, the majority of people with HIV/AIDS live in sub-Saharan Africa. While the increasing availability of antiretroviral therapy is improving the outlook for many, its effects are yet to reach all of those in need and patients still present with advanced disease. This paper reports findings from qualitative interviews with patients living with AIDS and their caregivers who were receiving palliative care from Hospice Africa Uganda (HAU). We aimed to understand what motivated patients and their families to seek formal healthcare, whether there were any barriers to help- seeking and how the help and support provided to them by HAU was perceived. Methods We invited patients with AIDS and their relatives who were newly referred to HAU to participate in qualitative interviews. Patients and carers were interviewed in their homes approximately four weeks after the patient’s enrolment at HAU. Interviews were translated, transcribed and analysed using narrative and thematic approaches. Results Interviews were completed with 22 patients (10 women and 12 men) and 20 family caregivers, nominated by patients. Interviews revealed the extent of suffering patients endured and the strain that family caregivers experienced before help was sought or accessed. Patients reported a wide range of severe physical symptoms. Patients and their relatives reported worries about the disclosure of the AIDS diagnosis and fear of stigma. Profound poverty framed all accounts. Poverty and stigma were, depending on the patient and family situation, both motivators and barriers to help seeking behaviour. Hospice services were perceived to provide essential relief of pain and symptoms, as well as providing rehabilitative support and a sense of caring. The hospice was perceived relieve utter destitution, although it was unable to meet all the expectations that patients had. Conclusion Hospice care was highly valued and perceived to effectively manage problems such as pain and other symptoms and to provide rehabilitation. Participants noted a strong sense of being “cared for”. However, poverty and a sense of stigma were widespread. Further research is needed to understand how poverty and stigma can be effectively managed in hospice care for patients for advanced AIDS and their families.
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Hutson SP. Climbing Back Up the Mountain: Reflections From an Exploration of End-of-Life Needs of Persons Living With HIV/AIDS in Appalachian Tennessee. Am J Hosp Palliat Care 2015; 33:972-976. [PMID: 26290520 DOI: 10.1177/1049909115600857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Little is known about the health access and end-of-life (EOL) concerns of persons living with HIV/AIDS (PLWHA) in Appalachia, where religious and cultural values are largely traditional. A qualitative, descriptive study with 9 participants was undertaken to assess EOL care needs among those from South Central Appalachian PLWHA. The focus of the study was to examine subjective data regarding EOL needs assessment related to advanced care planning. Five men and 4 women self-acknowledged a diagnosis of HIV/AIDS and completed a 2-hour face-to-face interview with the nurse researcher. Data were analyzed using qualitative descriptive content analysis methods, including data coding for emergent themes and metaphors. A common metaphor tied content to both struggle and triumph as well as the beauty and ruggedness of the Appalachian region: "Climbing Back up the Mountain." Rich descriptions of the significance of the metaphor match with stigma as the greatest hurdle to overcome in planning and interacting with others, including health care providers and significant others, about EOL care needs and advanced planning preferences. Further, the metaphor was derived directly from quotes offered by participants. Sources of stigma were often intersecting: the disease itself, associations with "promiscuity," sexual minority status, illicit drug use, and so on. Strong spiritual images were contrasted with a common avoidance and disdain of organized religion. Findings were used in refining plans for a larger study of EOL care needs and concerns on the population of PLWHA in 2 Southern Appalachian states. Comparison with other research and insights for providers is included.
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Affiliation(s)
- Sadie P Hutson
- College of Nursing, University of Tennessee, Knoxville, TN, USA
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Tamannai M, Kaah J, Mbah G, Ndimba J, D'Souza C, Wharin P, Hesseling PB. An evaluation of a palliative care outreach programme for children with Burkitt lymphoma in rural Cameroon. Int J Palliat Nurs 2015. [DOI: 10.12968/ijpn.2015.21.7.331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mona Tamannai
- Paediatrician, Universitätsmedizin Berlin
- Nurses, Banso Baptist Hospital
| | - Joel Kaah
- Nurse Assistant, Banso Baptist Hospital, Cameroon
- Nurses, Banso Baptist Hospital
| | | | | | - Catherine D'Souza
- Registrar, Nottingham University Hospitals, UK
- Nurses, Banso Baptist Hospital
| | - Paul Wharin
- Trustee, Beryl Thyer Memorial Africa Trust, UK
- Nurses, Banso Baptist Hospital
| | - Peter B Hesseling
- Emeritus Professor, Stellenbosch University, South Africa
- Nurses, Banso Baptist Hospital
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van Gurp J, Soyannwo O, Odebunmi K, Dania S, van Selm M, van Leeuwen E, Vissers K, Hasselaar J. Telemedicine's Potential to Support Good Dying in Nigeria: A Qualitative Study. PLoS One 2015; 10:e0126820. [PMID: 26030154 PMCID: PMC4452265 DOI: 10.1371/journal.pone.0126820] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/07/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES This qualitative study explores Nigerian health care professionals' concepts of good dying/a good death and how telemedicine technologies and services would fit the current Nigerian palliative care practice. MATERIALS AND METHODS Supported by the Centre for Palliative Care Nigeria (CPCN) and the University College Hospital (UCH) in Ibadan, Nigeria, the authors organized three focus groups with Nigerian health care professionals interested in palliative care, unstructured interviews with key role players for palliative care and representatives of telecom companies, and field visits to primary, secondary and tertiary healthcare clinics that provided palliative care. Data analysis consisted of open coding, constant comparison, diagramming of categorizations and relations, and extensive member checks. RESULTS The focus group participants classified good dying into 2 domains: a feeling of completion of the individual life and dying within the community. Reported barriers to palliative care provision were socio-economic consequences of being seriously ill, taboos on dying and being ill, restricted access to adequate medical-technical care, equation of religion with medicine, and the faulty implementation of palliative care policy by government. The addition of telemedicine to Nigeria's palliative care practice appears problematic, due to irregular bandwidth, poor network coverage, and unstable power supply obstructing interactivity and access to information. However, a tele-education 'lite' scenario seemed viable in Nigeria, wherein low-tech educational networks are central that build on non-synchronous online communication. DISCUSSION Nigerian health care professionals' concepts on good dying/a good death and barriers and opportunities for palliative care provision were, for the greater part, similar to prior findings from other studies in Africa. Information for and education of patient, family, and community are essential to further improve palliative care in Africa. Telemedicine can only help if low-tech solutions are applied that work around network coverage problems by focusing on non-synchronous online communication.
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Affiliation(s)
- Jelle van Gurp
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Olaitan Soyannwo
- Centre for Palliative Care Nigeria and Hospice and Palliative Care Unit, University College Hospital, Ibadan, Nigeria
| | - Kehinde Odebunmi
- Hospice and Palliative Care Unit, University College Hospital, Ibadan, Nigeria
| | - Simpa Dania
- Department of Telemedicine, University College Hospital, Ibadan, Nigeria
| | - Martine van Selm
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, Netherlands
| | - Evert van Leeuwen
- Department of IQ Healthcare, Ethics Section, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jeroen Hasselaar
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
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Herce ME, Elmore SN, Kalanga N, Keck JW, Wroe EB, Phiri A, Mayfield A, Chingoli F, Beste JA, Tengatenga L, Bazile J, Krakauer EL, Rigodon J. Assessing and responding to palliative care needs in rural sub-Saharan Africa: results from a model intervention and situation analysis in Malawi. PLoS One 2014; 9:e110457. [PMID: 25313997 PMCID: PMC4197005 DOI: 10.1371/journal.pone.0110457] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 09/19/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. METHODS Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP's first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. RESULTS The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. CONCLUSIONS We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.
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Affiliation(s)
- Michael E. Herce
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States of America
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Shekinah N. Elmore
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Noel Kalanga
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - James W. Keck
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Emily B. Wroe
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Atupere Phiri
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Alishya Mayfield
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Felix Chingoli
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Jason A. Beste
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Listern Tengatenga
- Neno District Health Office, Neno District Hospital, Ministry of Health, Government of the Republic of Malawi, Neno, Malawi
| | - Junior Bazile
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
| | - Eric L. Krakauer
- Partners in Health, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Division of Palliative Care, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jonas Rigodon
- Abwenzi Pa Za Umoyo, Neno, Malawi
- Partners in Health, Boston, Massachusetts, United States of America
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Besley C, Kariuki H, Fallon M. A pilot study investigating the effect of a patient-held pain assessment tool in palliative care outpatients attending a rural Kenyan hospital. Palliat Med 2014; 28:1156-60. [PMID: 24913921 DOI: 10.1177/0269216314536947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain is a frequent and distressing symptom in palliative care patients worldwide. Careful assessment is the first vital step to relieve this suffering. Assessment tools form a useful adjunct to pain management, but whether they make a difference to the patient is not known. AIM The objective of this study was to investigate whether the use of a patient-held pain assessment tool can make a difference in patient's pain control. SETTING AND PARTICIPANTS AIC Kijabe Hospital, Kenya, has had a nurse-led Palliative Care Service since 2002, with an annual case-load of around 600 patients. Study participants were recruited from among adult palliative care patients attending the Outpatient Department. DESIGN A quantitative experimental study methodology was employed. In the pre-intervention phase, pain was assessed at study entry and at 2 weeks, following 'standard' care at home; 49 patients were recruited for this phase. In the intervention phase, pain assessments were made at entry, with follow-up assessment after introduction to a patient-held pain assessment tool taken home by each patient; 50 patients were recruited for this phase. Analysis involved a comparison of baseline and 2-week pain scores between the two groups. RESULTS The results demonstrated that the use of a patient-held pain assessment tool led to an increase in the number of patients reaching satisfactory pain relief, from 30% in the pre-intervention group, to 69% in the intervention group. CONCLUSION This study has demonstrated that a simple pain assessment tool, when linked to some action, may help achieve better analgesia.
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Affiliation(s)
| | - Hellen Kariuki
- Department Medical Physiology, University of Nairobi, Nairobi, Kenya
| | - Marie Fallon
- Chair of Palliative Medicine Department, University of Edinburgh, Edinburgh, UK
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Aleksandrova-Yankulovska S, ten Have H. Survey of Staff and Family Members of Patients in Bulgarian Hospices on the Concept of “Good Death”. Am J Hosp Palliat Care 2013; 32:226-32. [DOI: 10.1177/1049909113516185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The concept of a “good death” has been intensely discussed over the past decades. The objective of this study is to investigate this concept among staff and patients’ relatives in 29 Bulgarian hospices and 5 palliative care units. Self-administered questionnaires were completed by 190 members of staff and 216 patients’ relatives. Death without pain and suffering and death in one’s sleep were leading concepts in both the groups. Staff preferred death in the presence of relatives, while relatives preferred fast and sudden death. Although we were able to define the common concept of a good death as painless and sudden death in one’s sleep, death is unique phenomenon and good palliative care should be based on communication with patients about their idea of a good death.
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Affiliation(s)
- Silviya Aleksandrova-Yankulovska
- Department of Medical Ethics, Management of Health Care and Information Technology, Faculty of Public Health, Medical University of Pleven, Pleven, Bulgaria
| | - Henk ten Have
- Center for Healthcare Ethics, Duquesne University, Pittsburgh, PA, USA
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Huang KTL, Owino C, Gramelspacher GP, Monahan PO, Tabbey R, Hagembe M, Strother RM, Njuguna F, Vreeman RC. Prevalence and correlates of pain and pain treatment in a western Kenya referral hospital. J Palliat Med 2013; 16:1260-7. [PMID: 24032753 DOI: 10.1089/jpm.2013.0080] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pain is often inadequately evaluated and treated in sub-Saharan Africa (SSA). OBJECTIVE We sought to assess pain levels and pain treatment in 400 hospitalized patients at a national referral hospital in western Kenya, and to identify factors associated with pain and pain treatment. DESIGN Using face-validated Kiswahili versions of two single-item pain assessment tools, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), we determined patients' pain levels. Additional data collected included patient demographics, prescribed analgesics, and administered analgesics. We calculated mean pain ratings and pain management index (PMI) scores. RESULTS Averaged between the NRS and FPS-R, 80.5% of patients endorsed a nonzero level of pain and 30% of patients reported moderate to severe pain. Older patients, patients with HIV, and cancer patients had higher pain ratings. Sixty-six percent of patients had been prescribed analgesics at some point during their hospitalization, the majority of which were nonopioids. A majority of patients (66%) had undertreated pain (negative scores on the PMI). CONCLUSION This study shows that hospitalized patients in Kenya are experiencing pain and that this pain is often undertreated.
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Affiliation(s)
- Kristin T L Huang
- 1 USAID - Academic Model Providing Access to Healthcare (AMPATH) , Eldoret, Kenya
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Luckett T, Davidson PM, Green A, Boyle F, Stubbs J, Lovell M. Assessment and management of adult cancer pain: a systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care. J Pain Symptom Manage 2013; 46:229-53. [PMID: 23159681 DOI: 10.1016/j.jpainsymman.2012.07.021] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 07/23/2012] [Accepted: 07/28/2012] [Indexed: 11/26/2022]
Abstract
CONTEXT Cancer pain is a common, burdensome problem, which is not well managed despite evidence-based guidelines. OBJECTIVES To develop insights for managing barriers and optimizing facilitators to adult cancer pain assessment and management within a comprehensive framework of patient care. METHODS We undertook a systematic review and synthesis of qualitative studies. Medline, PsycINFO, Embase, AMED, CINAHL, and Sociological Abstracts were searched from May 20 to 26, 2011. To be included, the articles had to be published in a peer-reviewed journal since 2000; written in English; and report original qualitative studies on the perspectives of patients, their significant others, or health care providers. Article quality was rated using the checklist of Kitto et al. Thematic synthesis followed a three-stage approach using Evidence for Policy and Practice Information and Co-ordinating Centre-Reviewer 4 software: 1) free line-by-line coding of "Results," 2) organization into "descriptive" themes, and 3) development of "analytical" themes informative to our objective. At Stage 3, a conceptual framework was selected from the peer-reviewed literature according to prima facie "fit" for descriptive themes. RESULTS Of 659 articles screened, 70 met the criteria, reporting 65 studies with 48 patient, 19 caregiver, and 21 health care provider samples. Authors rarely reported reflexivity or negative cases. Mead and Bower's model of patient-centered care accommodated 85% of the descriptive themes; 12% more related to the caregiver and service/system factors. Three themes could not be accommodated. CONCLUSION Findings highlight the need to integrate patient/family education within improved communication, individualize care, use more nonpharmacological strategies, empower patients/families to self-manage pain, and reorganize multidisciplinary roles around patient-centered care and outcomes. These conclusions require validation via consensus and intervention trials.
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Affiliation(s)
- Tim Luckett
- Improving Palliative Care through Clinical Trials, New South Wales Palliative Care Clinical Trials Collaborative, Sydney, NSW 2007, Australia.
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Huang KT, Owino C, Vreeman RC, Hagembe M, Njuguna F, Strother RM, Gramelspacher GP. Assessment of the face validity of two pain scales in Kenya: a validation study using cognitive interviewing. BMC Palliat Care 2012; 11:5. [PMID: 22512923 PMCID: PMC3393614 DOI: 10.1186/1472-684x-11-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Accepted: 04/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients in sub-Saharan Africa commonly experience pain, which often is un-assessed and undertreated. One hindrance to routine pain assessment in these settings is the lack of a single-item pain rating scale validated for the particular context. The goal of this study was to examine the face validity and cultural acceptability of two single-item pain scales, the Numerical Rating Scale (NRS) and the Faces Pain Scale-Revised (FPS-R), in a population of patients on the medical, surgical, and pediatric wards of Moi Teaching and Referral Hospital in Kenya. METHODS Swahili versions of the NRS and FPS-R were developed by standard translation and back-translation. Cognitive interviews were performed with 15 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya. Interview transcripts were analyzed on a question-by-question basis to identify major themes revealed through the cognitive interviewing process and to uncover any significant problems participants encountered with understanding and using the pain scales. RESULTS Cognitive interview analysis demonstrated that participants had good comprehension of both the NRS and the FPS-R and showed rational decision-making processes in choosing their responses. Participants felt that both scales were easy to use. The FPS-R was preferred almost unanimously to the NRS. CONCLUSIONS The face validity and acceptability of the Swahili versions of the NRS and FPS-R has been demonstrated for use in Kenyan patients. The broader application of these scales should be evaluated and may benefit patients who currently suffer from pain.
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Affiliation(s)
- Kristin Tl Huang
- USAID - Academic Model Providing Access to Healthcare (AMPATH), P,O, Box 4806, Eldoret, Kenya.
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Gysels M, Pell C, Straus L, Pool R. End of life care in sub-Saharan Africa: a systematic review of the qualitative literature. BMC Palliat Care 2011; 10:6. [PMID: 21388538 PMCID: PMC3070681 DOI: 10.1186/1472-684x-10-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 03/09/2011] [Indexed: 11/17/2022] Open
Abstract
Background End of life (EoL) care in sub-Saharan Africa still lacks the sound evidence-base needed for the development of effective, appropriate service provision. It is essential to make evidence from all types of research available alongside clinical and health service data, to ensure that EoL care is ethical and culturally appropriate. This article aims to synthesize qualitative research on EoL care in sub-Saharan Africa to inform policy, practice and further research. It seeks to identify areas of existing research; describe findings specifically relevant to the African context; and, identify areas lacking evidence. Methods Relevant literature was identified through eight electronic databases: AMED, British Nursing Index & Archive, CINAHL, EMBASE, IBSS, MEDLINE, PsycINFO, and the Social Sciences Citation Index; and hand searches. Inclusion criteria were: published qualitative or mixed-method studies in sub-Saharan Africa, about EoL care. Study quality was assessed using a standard grading scale. Relevant data including findings and practice recommendations were extracted and compared in tabular format. Results Of the 407 articles initially identified, 51 were included in the qualitative synthesis. Nineteen came from South Africa and the majority (38) focused on HIV/AIDS. Nine dealt with multiple or unspecified conditions and four were about cancer. Study respondents included health professionals, informal carers, patients, community members and bereaved relatives. Informal carers were typically women, the elderly and children, providing total care in the home, and lacking support from professionals or the extended family. Twenty studies focused on home-based care, describing how programmes function in practice and what is needed to make them effective. Patients and carers were reported to prefer institutional care but this needs to be understood in context. Studies focusing on culture discussed good and bad death, culture-specific approaches to symptoms and illness, and the bereavement process. Conclusions The data support or complement the findings from quantitative research. The review prompts a reconsideration of the assumption that in Africa the extended family care for the sick, and that people prefer home-based care. The review identifies areas relevant for a research agenda on socio-cultural issues at the EoL in sub-Saharan Africa.
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Affiliation(s)
- Marjolein Gysels
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), C/Rosselló 132 SA 1ª, Barcelona 08036, Spain.
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Murakawa Y, Nihei Y. Understanding the concept of a 'good death' in Japan: differences in the views of doctors, palliative and non-palliative ward nurses. Int J Palliat Nurs 2009; 15:282-9. [PMID: 19568215 DOI: 10.12968/ijpn.2009.15.6.42987] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Achieving a 'good death' is the ultimate goal for medical staff caring for terminally ill cancer patients, but the exact definition of a 'good death' is subject to interpretation. This exploratory study investigates the differences in how Japanese cancer care staff perceive a 'good death' by using factor analysis. METHOD Participants included doctors, palliative and non-palliative ward nurses working in Miyagi Cancer Center, Natori, Japan. The various components of a 'good death' for cancer patients have been identified in a previous Japanese study. In the present study, respondents were asked to state the percentages of patients for which the component had been achieved, the extent to which the respondent contributed to achieving the component, and the concrete means they would use to ensure that patients were free from psychological distress and prepared for dying. RESULTS Medical staff had largely similar views on the percentage of patients for which a component of 'good death' was achieved. All the achievement ratings determined in the present study were considerably lower than the necessity ratings given by non-medical staff in a previous study. There were differences among medical staff with respect to their contribution to achieving a component of 'good death' and the concrete means they would use to achieve a 'good death'.
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Affiliation(s)
- Yasuko Murakawa
- Miyagi Cancer Center, Tohoku University, Sendai, Miyagi Prefecture, Japan.
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Withell B. The prebereavement psychological needs of AIDS-affected adolescents in Uganda. Int J Palliat Nurs 2009; 15:128-33. [DOI: 10.12968/ijpn.2009.15.3.41091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Uwimana J, Struthers P. Met and unmet palliative care needs of people living with HIV/AIDS in Rwanda. SAHARA J 2008; 4:575-85. [PMID: 18040536 DOI: 10.1080/17290376.2007.9724819] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The rising number of people living with HIV/AIDS (PLWHA) worldwide has made health care professionals and policy makers search for accessible health care that will meet the needs of people who are suffering from the disease and enhance their quality of life (QoL). This study investigated met and unmet palliative care needs of PLWHA in selected areas in Rwanda. The study sample included 306 participants: PLWHA, health care professionals and coordinators of HIV/AIDS units. Quantitative and qualitative methodologies were used. The data were analysed separately and then triangulated. In the findings, over 50% of PLWHA had symptoms related to HIV/AIDS most of the time, with the most common symptom being pain. Participation in activities of daily living was significantly associated with the health status of PLWHA (p<0.001). The most common perceived palliative care needs of PLWHA were medical needs, psychosocial needs and the need for financial assistance (77%); home-based care (47%); nutritional support (44%); and pain relief and management of other symptoms (43%). Most PLWHA indicated these palliative care needs were unmet, in particular the need for pain relief, symptom management, financial assistance and nutritional support. Over 50% of health care professionals reported they were not trained in palliative care. They indicated that inadequate policy and resources were the main obstacles to the provision of optimal palliative care. Addressing unmet palliative care needs would enhance the QoL of PLWHA. In addition, developing policy related to the provision of palliative care and building the capacity of health care providers is essential for the provision of adequate palliative care services in Rwanda.
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Affiliation(s)
- J Uwimana
- Kigali Institute of Science and Technology.
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Uwimana J, Struthers P. Assessment of palliative care needs for people living with HIV/AIDS in Rwanda. PROGRESS IN PALLIATIVE CARE 2008. [DOI: 10.1179/096992608x296969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Izuha A, Suzuki M, Murakawa M, Yasumura S. Comparison of the Perceptions of City Residents and Physicians Regarding ^|^ldquo;Good Death^|^rdquo; in a Terminal Cancer Setting in Fukushima, Japan. ACTA ACUST UNITED AC 2008. [DOI: 10.14442/general2000.9.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
One of the primary outcomes of end-of-life care should be the experience of a good death by the patient and the family. Yet there is no clear, shared understanding of what a good death is. This analysis of the concept of a good death has been guided by Rodgers' evolutionary method of concept analysis.(1) Forty-two articles were analyzed. There was the strong agreement that the concept of a good death was highly individual, changeable over time, and based on perspective and experience. Medical, nursing, and patient perspectives, as well as literature in sociology, include the following attributes of a good death, listed in order of frequency of appearance in the literature: being in control, being comfortable, sense of closure, affirmation/value of the dying person recognized, trust in care providers, recognition of impending death, beliefs and values honored, burden minimized, relationships optimized, appropriateness of death, leaving a legacy, and family care.
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Affiliation(s)
- Karen A Kehl
- School of Nursing, University of Wisconsin-Madison, and Hospice Care Inc, Madison, Wisconsi, USA.
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Miyashita M, Sanjo M, Morita T, Hirai K, Uchitomi Y. Good death in cancer care: a nationwide quantitative study. Ann Oncol 2007; 18:1090-7. [PMID: 17355953 DOI: 10.1093/annonc/mdm068] [Citation(s) in RCA: 213] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aims of this study were to (i) conceptualize dimensions of a good death in Japanese cancer care, (ii) clarify the relative importance of each component of a good death and (iii) explore factors related to an individual's perception of the domains of a good death. METHODS The general population was sampled using a stratified random sampling method (n = 2548; response rate, 51%) and bereaved families from 12 certified palliative care units were surveyed as well (n = 513; 70%). We asked the subjects about the relative importance of 57 components of a good death. RESULTS Explanatory factor analysis demonstrated 18 domains contributing to a good death. Ten domains were classified as 'consistently important domains', including 'physical and psychological comfort', 'dying in a favorite place', 'good relationship with medical staff', 'maintaining hope and pleasure', 'not being a burden to others', 'good relationship with family', 'physical and cognitive control', 'environmental comfort', 'being respected as an individual' and 'life completion'. CONCLUSIONS We quantitatively identified 18 important domains that contribute to a good death in Japanese cancer care. The next step of our work should be to conduct a national survey to identify what is required to achieve a good death.
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Affiliation(s)
- M Miyashita
- Department of Adult Nursing/Palliative Care Nursing, School of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Webster R, Lacey J, Quine S. Palliative Care: A Public Health Priority in Developing Countries. J Public Health Policy 2007; 28:28-39. [PMID: 17363933 DOI: 10.1057/palgrave.jphp.3200097] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Palliative care is an emerging specialist discipline worldwide with the majority of services located in developed countries. Developing countries, however, have higher incidences of cancer and AIDS and most of these patients would benefit from palliative care. While there is prominent coverage of this issue in the palliative care literature, there is limited coverage in the specialist public health literature, which suggests that the challenges of palliative care may not yet have been generally recognized as a public health priority, particularly in developing countries. The aim of this article is to introduce the topic of "Palliative care in developing countries" into the specialist public health literature to raise awareness and stimulate debate on this issue among public health professionals and health policy makers, thereby potentially facilitating establishment of palliative care services in developing countries.
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Affiliation(s)
- Ruth Webster
- The George Institute for International Health, Cardiovascular Division, Camperdown, NSW, Australia.
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McPherson CJ, Wilson KG, Murray MA. Feeling like a burden to others: a systematic review focusing on the end of life. Palliat Med 2007; 21:115-28. [PMID: 17344260 DOI: 10.1177/0269216307076345] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Research into the burden of illness has focused predominantly on family caregivers, with little consideration of the other side of the caregiving relationship-care recipients' perspectives on having become a 'burden to others'. However, there is now a small but growing body of evidence to suggest that worry about creating burden to others is a common and troubling concern for people who are nearing the end of their lives. This concern is referred to as 'self-perceived burden'. The present study provides a systematic review of the literature, addressing self-perceived burden at the end of life. Using standard methods, literature was searched for relevant studies in palliative care and related fields. The review revealed that self-perceived burden is reported as a significant problem by 19- 65% of terminally ill patients. It is correlated with loss of dignity, suffering, and a 'bad death'. Self-perceived burden has also been identified as a relevant factor in death-hastening acts among patients with life-threatening illness, as well as in clinical decisions, such as the choice of place of care at the end of life, advance directives, and acceptance of treatment. Given the unique challenges faced by patients with advanced disease and their families, there is a need for further investigation into this under-researched area.
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Orem J, Otieno MW, Remick SC. Challenges and opportunities for treatment and research of AIDS-related malignancies in Africa. Curr Opin Oncol 2006; 18:479-86. [PMID: 16894296 DOI: 10.1097/01.cco.0000239887.90665.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Following our review of AIDS-associated cancer in developing nations in 2004, we sought to update recent publications and review data on the challenges and opportunities for the treatment and research of AIDS malignancies in Africa. RECENT FINDINGS It is apparent that the burden of AIDS-related malignancies and other virus-associated tumors is significant and increasing in Africa. Several recent studies report findings on conjunctival squamous cell carcinoma and there is a report that Hodgkin's disease, a non-AIDS-defining neoplasm, is increasing in incidence. International collaborative partnerships dedicated to AIDS malignancies in developing countries are feasible and invaluable for clinical strategies to address this aspect of the pandemic. A departure point is the ongoing work of the East Africa - Case Western Reserve University Collaboration in AIDS malignancies. SUMMARY The burden of neoplastic complications of HIV infection and endemic virus-associated tumors are assuming increasing significance in Africa. There is a need to develop nonmyelotoxic therapies and approaches that are hypothesis-driven and pathogenesis-based. The scarcity and shortages in this region demand that our scientific and therapeutic strategies are both suitable and pragmatic for testing in this setting. It is also imperative that African investigators lead us in this important endeavor.
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Affiliation(s)
- Jackson Orem
- Uganda Cancer Institute, Mulago Hospital and the Makerere University School of Medicine, Kampala, Uganda.
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