Support for Informal Caregivers in Canada: A Scoping Review from a Hospice and Palliative/End-of-Life Care Lens

Objective: Informal caregivers (ICs) providing care for those at the end-of-life face physical, psycho-social, emotional, and/or financial challenges. However, there is a paucity of research towards the effectiveness of available interventions for this vulnerable population. The purpose of this scoping review was to investigate the availability and efficacy of interventions for ICs providing hospice and palliative/end-of-life care in Canada. Methods: Using Arksey and O’Malley's five step framework, a scoping review was conducted in the spring of 2020. Key electronic healthcare, social sciences, and grey literature databases were searched. Relevant publications from 2005 to 2019 were screened for inclusion criteria, and a thematic content analysis was conducted to summarize all key findings. Results: Initial searches yielded 145 results out of which 114 distinct articles were obtained. De-duplication and final screening yielded 28 sources which met inclusion criteria (22 peer-reviewed articles [78%] and 6 grey sources [22%]; 12 qualitative papers [42%]). Through thematic content analysis, four major themes were identified: [1] Direct financial support, [2] Direct psycho-sociospiritual support, [3] Indirect patient information provision/education, and [4] Indirect patient support. Conclusions: Healthcare practitioners should provide information on patient care and financial aid to ICs. Policies should aim to expand eligibility for and access to financial aid, in particular the Compassionate Care Benefits (CCB). Future research should focus on exploring other interventions, such as physical activities, to better support this vulnerable population. The results from this review will help inform and improve the well-being of ICs providing end-of-life care in Canada and beyond.

How does spirituality manifest in family caregivers of terminally ill cancer patients? A qualitative secondary analysis

OBJECTIVE

Considering the risk of spiritual distress among terminally ill patients, experts long agree that spiritual care has to be an integral component of palliative care. Despite this consensus, the role of spirituality among family caregivers remains largely unexplored. We aimed to describe how spirituality manifests in the lived experience of family caregivers (FCs) in a palliative care context.

METHOD

As part of a secondary analysis, data derived from two qualitative primary studies on FCs' burdens and needs in the context of caring for a patient with a diagnosis of incurable cancer. Previously transcribed interviews were examined by means of a thematic analysis, transcending the focus of the primary studies to examine how spirituality arises and/or persists in the life of FCs from the time of diagnosis of incurable cancer up until bereavement.

RESULTS

Twenty-nine narratives were explored and all included spirituality as a relevant theme. Analysis revealed four aspects associated with the presence of spirituality among FCs' experiences: "Connectedness," "Religious Faith," "Transcendence," "Hope," and a fifth overarching aspect which we named "Ongoing integration of spiritual experience." Spirituality appeared as a multilayered phenomenon and was shaped individually among FCs' narratives.

SIGNIFICANCE OF RESULTS

In view of the results, exploring and discussing spirituality and underlying experiences in the situation as an FC seems likely to widen the perspective on FCs' problems and needs. Further research on spiritual needs among FCs of patients with incurable life-limiting cancer is deemed necessary.

Palliative Care Home Support Packages (PEACH): a carer cross-sectional survey

BACKGROUND

In December 2013, a partnership between five local health districts and a non-governmental organisation implemented the Palliative Care Home Support Packages (PEACH) Program. The PEACH Program aims to support palliative care clients in their last days of life at their own home. This study sought to evaluate the quality of care delivered by the service from the perspective of clients' primary carers.

METHODS

A letter was sent to carers of clients 6-10 weeks after the client's death, inviting them to participate in an anonymous survey. The survey measured the level of satisfaction on various aspects of the service using FAMCARE and Likert scales, and invited for comments about the care received and suggestions for improvement.

RESULTS

Out of 17 aspects of care provided by the PEACH Program, 13 were scored with 'exceptional' or 'acceptable performance'. The highest satisfaction was observed in meeting clients' physical needs and providing pain relief. The most dissatisfaction was observed in addressing spiritual matters, family conferences and information about treatment side effects. Ninety-five per cent of responses were either 'satisfied' or 'very satisfied' with the overall care provided at home during the last week of the client's life.

CONCLUSION

The results of this research provide further evidence to the field of what constitutes a good home death and the support mechanisms required to enable this. The results also have strong implications on how local services provided by the PEACH Program are delivered in the future.

Spirituality among family caregivers in palliative care: an integrative literature review

BACKGROUND

Family caregivers experience spiritual and existential concerns while caring for their terminally ill family members.

AIM

To evaluate and synthesise studies on spirituality among family caregivers in palliative care.

DESIGN

An integrative literature review of peer-reviewed articles published between 2000 and 2016.

SAMPLE

Participants were family caregivers (parents, spouses, relatives or friends) caring for an adult (age>18 years) family member with a terminal illness in a palliative care setting.

RESULTS

Data from 26 published research papers were systematically analysed. Five themes were identified regarding spirituality and family caregiving: a close and meaningful connection, spirituality as a way of coping, spiritual needs and expressions among family caregivers, spirituality to transcend fears, and spirituality in family caregivers' decision-making.

IMPLICATIONS FOR PRACTICE

Nurses are encouraged to explore the spirituality and spiritual experiences of family caregivers to support their spiritual wellbeing while caring for their terminally ill family members.

Preferred and Actual Location of Death: What Factors Enable a Preferred Home Death?

BACKGROUND

Fulfillment of patient preferences for location of dying is of continued end-of-life care interest. Of those voicing a preference, most prefer home. However the majority of deaths occur in an institutional setting.

OBJECTIVES

The study objective was to report on the congruence between the last preferred and actual location of death among adult Nova Scotians who died from chronic disease, and to identify individual, illness-related, and environmental factors associated with achieving a preferred home death.

METHODS

The study employed a population-based mortality follow-back telephone survey interview. Subjects were eligible death certificate identified informants (next-of-kin) of adults (aged 18+) (n = 1316) who died of advanced chronic diseases in the Canadian province of Nova Scotia between June 2009 and May 2011 who were knowledgeable about the decedent's care over the last month of life. Congruence was assessed as to whether or not the decedent died in their preferred death location. Among decedents preferring a home death, individual, illness-related, and environmental risk factor multivariable analyses were used to identify predictors of home death achievement.

RESULTS

Among all who voiced a preference (n = 606), 52% died in their preferred location (kappa: 0.29). Factors contributing independently to achievement of a preferred home death were emotional needs being met, nursing and family physician home visits, palliative care program involvement, and being at home for the majority of the last month.

CONCLUSIONS

This study identifies elements of primary and integrated care that address the gap between preferred and actual place of care.

Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: does location matter?

BACKGROUND

Improving end-of-life care is an important international issue. Recently Nova Scotia researchers conducted a mortality follow-back survey to provide a population-based description of care provided to adults during their last 30 days of life as perceived by knowledgeable bereaved family members. Here we describe the relationship between the location where the decedent received the majority of care during their last 30 days and the informant's perception of the extent of unmet need, as defined by multiple domains of patient-focused, family-centred care.

METHOD

Death certificate identified informants (next-of-kin) of eligible adults who died between June 2009 and May 2011, in Nova Scotia, Canada were invited to participate in a telephone interview based on the After-Death Bereaved Family Member Interview. Whether or not the informant expressed unmet need or concerns for six patient-focused, family-centred care domains were assessed in relation to the location where the majority of care occurred during the decedent's last 30 days.

RESULTS

1358 informants took part (25% response rate). Results of 1316 eligible interviews indicated home (39%) was the most common location of care, followed by long-term care (29%), hospital (23%) and hospital-based palliative-care units (9%). Unmet need ranged from 5.6% for dyspnea help to 66% for the emotional and spiritual needs of the family. Although the mean score for overall satisfaction was high (mean = 8.7 in 1-10 scale; SD 1.8), 57% were not completely satisfied. Compared to home, adjusted results indicated greater dissatisfaction with overall care and greater communication concerns in the hospital. Greater unmet need occurred at home for dyspnea. Less overall dissatisfaction and unmet need were expressed about care provided in long-term care facilities and hospital-based palliative-care units.

CONCLUSION

Bereaved informants were generally highly satisfied with the decedent's care during their last 30 days but variations were evident. Overall, no one location stood out as exceptionally different in terms of perceived unmet need within each of the patient-focused, family-centred care domains. Communication in various forms and family emotional and spiritual support were consistently viewed as lacking in all locations and identified as targeted areas for impacting quality care at end of life.

Challenges and strategies in the administration of a population based mortality follow-back survey design

Population-based mortality follow-back survey designs have been used to collect information concerning end-of-life care from bereaved family members in several countries. In Canada, this design was recently employed to gather population-based information about the end-of-life care experience among adults in Nova Scotia as perceived by the decedent's family. In this article we describe challenges that emerged during the implementation of the study design and discuss resolutions strategies to help overcome them. Challenges encountered included the inability to directly contact potential participants, difficulties ascertaining eligibility, mailing strategy complications and the overall effect of these issues on response rate and subsequent sample size. Although not all challenges were amenable to resolution, strategies implemented proved beneficial to the overall process and resulted in surpassing the targeted sample size. The inability to directly contact potential participants is an increasing reality and limitations associated with this process best acknowledged during study development. Future studies should also consider addressing participant concerns pertaining to their eligibility and use of a more cost effective mailing strategy.