Identifying Core Domains to Assess the "Quality of Death": A Scoping Review

CONTEXT

There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines.

OBJECTIVES

Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems.

METHODS

PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles.

RESULTS

A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication.

CONCLUSION

The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.

Exploring symptom meaning: perspectives of palliative care physicians

CONTEXT

Understanding patients' symptom experiences is essential to providing effective clinical care. The discussion between patients and physicians of symptom meaning and its significance, however, is ill understood.

OBJECTIVES

To investigate palliative care physicians' understanding of symptom meaning, and their experiences of and attitudes towards the discussion of symptom meaning with patients.

METHODS

Semi-structured interviews were conducted (N = 17) across Sydney, Australia. Transcripts were analysed using framework analysis.

RESULTS

Six key themes were identified: (1) definitions of symptom meaning (causal meanings, functional impact, existential impact, and cascade of meanings); (2) meanings are personal (demographic, culture, spiritual, and family differences); (3) eliciting meanings requires subtlety and trust (following the patient's cues); discussing meaning can be (4) hard (for the patient and health professional); (5) therapeutic (assuaging fears, feeling listened to and valued, increased sense of control, and reduced symptom distress); and (6) enhances clinicians' practice and work satisfaction (provision of more tailored care, reassurance through the provision of information, and strengthening of doctor-patient relationship).

CONCLUSIONS

Exploring symptom meaning can serve to provide information, alleviate anxiety, and facilitate individualised care, but only when patients present cues or are open to discuss symptom-related concerns. However, various barriers hinder such dialogue in consultations. Greater awareness of symptom meaning and its influence may facilitate physicians exploring symptom meaning more with patients in the future.

What Aspects of Quality of Life Are Important From Palliative Care Patients' Perspectives? A Systematic Review of Qualitative Research

CONTEXT

Despite the availability of numerous tools professing to measure quality of life (QOL) in the palliative care setting, no single instrument includes all patient-valued domains.

OBJECTIVES

To identify which aspects of QOL are important from palliative care patients' perspectives, aiding coverage, and content validity evaluation of available tools.

METHODS

A systematic review and synthesis of qualitative research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. ASSIA, CINAHL, Cochrane library, Embase, Medline, PsycINFO, and PubMed were searched from database inception to December 31, 2015. Published, peer-reviewed, English-language articles reporting primary qualitative data investigating QOL domains in adults with a progressive, life-limiting illness were included. Studies a priori exploring a chosen aspect of QOL were not included. Articles scoring ≤2 on reporting quality were excluded. Framework synthesis was used to identify key themes across the studies.

RESULTS

Overall, 3589 articles were screened and 24 studies were included. Eight important aspects of QOL were identified: physical; personal autonomy; emotional; social; spiritual; cognitive; healthcare; and preparatory. All but one study discussed spiritual aspects, whereas only six studies mentioned cognitive aspects.

CONCLUSION

A broad range of domains are important to the QOL of people with life-limiting illnesses receiving palliation. Refinement of measures is needed to help ensure services address issues valued by patients such as preparation for death and aspects of health care provision, elements which are seldom included in currently available preference-based measures used to inform value for money decisions in palliative care.

Quality of Care and Satisfaction With Care on Palliative Care Units

CONTEXT

There is little research on quality of care specific to palliative care units (PCUs).

OBJECTIVES

To delineate important aspects of satisfaction with care and quality of care on a PCU, as described by inpatients, family caregivers, and health care professionals.

METHODS

Qualitative interviews and focus groups were conducted across four Toronto PCUs, with a total of 46 patient/caregiver interviews and eight staff focus groups. Interviews and focus groups were semistructured to elicit comments about satisfaction with care and quality of care for inpatients and families on a PCU. Data were analyzed using a grounded theory method, with an inductive, constant comparison approach to identify themes, and were coded to saturation.

RESULTS

Key elements of quality care and patient satisfaction on a PCU were grouped into six domains: 1) interprofessional team: a team of experts comprising multiple disciplines functioning as a unit; 2) communication: developing rapport, addressing expectations, providing information, listening actively, and facilitating end-of-life discussions; 3) attentive, personalized care: anticipatory and responsive compassionate care with tailored management of physical and nonphysical symptoms; 4) family-centered: support of patients and caregivers within a family; 5) accessible and consistent: appropriate resources and adequate staff to provide consistent care; and 6) supportive setting: a bright noninstitutionalized setting allowing both privacy and socialization.

CONCLUSION

The elements identified support the delivery of quality care. They may act as a guide for those planning to develop PCUs and form the basis for measures of satisfaction with care.

Swallowing problems at the end of the palliative phase: incidence and severity in 164 unsedated patients

Swallowing problems are reported to be a common finding in patients who receive palliative care. In existing literature, the incidence of swallowing problems is mostly described in small numbers of patients at the start of the palliative phase. As we hypothesized that the incidence of dysphagia might increase as the palliative phase progresses, this study describes the incidence of swallowing problems and related problems in 164 unsedated patients at the end of the palliative phase, defined by the last 72 h before their death. To determine the incidence of swallowing problems and related problems, questionnaires were completed bereaved by relatives and nursing staff. Our data shows that in the palliative phase the incidence of swallowing problems can be as high as 79 %. A significant correlation was found between swallowing problems and reduced psycho-social quality of life as assessed by nursing staff (ρ = -.284). Overall the nursing staff rated the incidence and severity of swallowing problems (and related problems like frequent coughing, loss of appetite, and problems with oral secretions) lower than the relatives. This study suggests that incidence of swallowing problems at the end of the palliative phase is high and that these difficulties may not only result in discomfort for patients, but also can raise concern for caregivers. More information and education on management of swallowing problems in palliative settings might be needed for both relatives and nursing staff. However, the data also suggest that any intervention should be proportional to the level of distress caused by the intervention.

Association between unmet needs and quality of life in hospitalised cancer patients no longer receiving anti-cancer treatment

Assessing the quality of life and unmet needs of cancer patients is an integral part of palliative care. This cross-sectional study sought to determine whether there is an association between quality of life and unmet needs, anxiety and depression in cancer patients who are no longer receiving anti-cancer treatment. The sample consisted of 93 patients from the oncology department at the University Hospital in Ostrava for whom further cancer treatment had been terminated as ineffective in halting the progression of their cancer. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Patient Needs Assessment in Palliative Care (PNAP) questionnaire, and the Hospital Anxiety and Depression Scale (HADS) were used to collect data. The overall quality of life score was quite low at 46. Most unmet needs were defined in terms of physical, psychological or spiritual needs. Correlations were found between impaired quality of life and lower Karnofsky scores (r = 0.50); increased physical (r = 0.52), psychological (r = 0.44) and spiritual (r = 0.36) needs; and higher levels of anxiety (r = -0.30) and depression (r = -0.68). Effective management of patients' physical (pain, fatigue and depression), psychological and spiritual needs may improve their quality of life.

Survey of Staff and Family Members of Patients in Bulgarian Hospices on the Concept of “Good Death”

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.

Goals set in the land of the living/dying: a longitudinal study of patients living with advanced cancer

A longitudinal qualitative research study was undertaken to provide an understanding of a prolonged experience of advanced cancer, as seen through the eyes of dying individuals. Using a variant of the grounded theory method, the authors theoretically sampled, from outpatient clinics in a large comprehensive cancer treatment center, 27 patients with either advanced lung or gastrointestinal cancer who had an expected survival of up to 2 years. The authors conducted a total of 54 interviews with these patients to learn of their experience of advanced cancer. The authors represent their experience with the core category: striving to grow in the land of the living/dying, symbolizing their sense of finding themselves in a borderland between life and death where their efforts focused on 3 common goals. controlling dying, valuing life in the present, and creating a living legacy. They provide a longitudinal account of how these goals were addressed throughout the illness trajectory and discuss the theoretical and clinical implications of this understanding for the experience of dying from advanced cancer.

Encouraging patients and families to influence change on a palliative care unit: value of patient satisfaction surveys

This article describes how a series of patient satisfaction surveys on a palliative care unit were used to help influence the care provided to patients and their families. Innovative interventions aimed at addressing areas of lower satisfaction identified in the initial survey are described. The results from a follow-up survey provided the opportunity to evaluate whether our interventions were effective in improving patient satisfaction and highlight new areas of concern needing to be addressed.

Making sense of health and illness in palliative care: Volunteers' perspectives

Objective:

To encourage communication and contribute to the palliative care movement's need for interdisciplinary care, this article offers to explore the stance of volunteers on two fundamental concepts, “health” and “illness,” as well as their related understanding of “palliative care.” Volunteers' understandings are then compared with the concepts put forth by the Canadian Hospice Palliative Care Association (CHPCA) in its “Model to Guide Hospice Palliative Care.”

Method:

Focus groups with volunteers, and individual interviews with coordinators from five selected palliative care community action organizations from across Canada, are used. A total of 65 participants from three Canadian provinces were interviewed.

Results:

Participants view illness as a subjective, multidimensional, and transformative experience that requires multiple adjustments. It is an impediment to personal equilibrium and a challenge for the terminally ill and their close ones. Health, on the other hand, is a complex phenomenon that consists of physical, psychological, social, and spiritual well-being. For participants, health is most often embodied by a person's capacity to adjust to their challenging circumstances. Both volunteers and coordinators see palliative care as an alternative approach to care that centers on helping patients and their families through their ordeal by offering comfort and respite, and helping patients enjoy their life for as long as possible.

Significance of Results:

Participants describe illness as a destabilizing loss and palliative care as a means to compensate for the numerous consequences this loss brings; their actions reflect these principles and are compatible with the CHPCA model.