Users' views on palliative care services: ethical implications

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice

BACKGROUND

Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff.

AIM

To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice.

DESIGN

Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative.

DATA SOURCES

Seven databases (MEDLINE, Philosopher's Index, EMBASE, PsycINFO, LILACS, Web of Science and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges.

RESULTS

A total of 8074 records were screened. Thirteen studies from nine countries were included. Challenges were organised into six themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy).

CONCLUSION

Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, for example, navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.

Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities

Background

Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.

Main body

Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.

Conclusion

This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.

Struggling with the Fragility of Life: a relational-narrative approach to ethics in palliative nursing

In nursing ethics the role of narratives and dialogue has become more prominent in recent years. The purpose of this article is to illuminate a relational-narrative approach to ethics in the context of palliative nursing. The case study presented concerns a difficult relationship between oncology nurses and a husband whose wife was hospitalized with cancer. The husband’s narrative is an expression of depression, social isolation and the loss of hope. He found no meaning in the process of dying and death. The oncology nurses were not able to recognize his emotional and existential problems. A narrative perspective inspired by relational ethics indicates that participants may develop a relational narrative that seeks good for all involved in a situation. In palliative nursing this entails open communication about the fragility of life and approaching death. In relational narratives, answers to these ethical dilemmas are co-authored, contingent and contextual.

Student Nurses Learning about Death, Dying, and Loss: Too Little, Too Late?

Concerns about the care provided to people dying from life-threatening illness have prompted a number of international reforms to improve the quality of palliative and end-of-life (EOL) care. The majority of this care is provided by nurses. They spend more time with dying patients than any other health professionals and therefore, need specific clinical skills and knowledge. Palliative and EOL care education is increasingly being positioned as a specialism, available only to a small number of registered nurses as part of continuing professional development. However, increasing numbers of patients with life-threatening illness are being treated in non-specialist settings by nurses with a generalist education. Furthermore, undergraduate nurse education has traditionally had a limited focus on palliative and EOL care, hence claims that undergraduate nursing curricula are inadequate. Drawing on an international literature, this review explores the evidence about the adequacy of undergraduate curricula in this area. It considers the extent to which palliative and EOL curriculum is included in undergraduate nurse education and draws upon evidence from students and registered nurses, who as consumers of education, report feeling unprepared to care for and communicate with, dying patients.

End-of-life education in the pre-registration nursing curriculum: Patient, carer, nurse and student perspectives

Providing good quality care for dying patients has been highlighted as a national priority in the UK. The Department of Health’s end-of-life (EOL) care strategy outlines how patients should be cared for to ensure that they experience a ‘good death’. Nurses have an important role to play in the delivery of EOL care and need to be knowledgeable about the palliation of symptoms and the social context of death and dying. Traditionally, the pre-registration nursing curriculum has had a limited emphasis on EOL care. While there have been significant developments in nurse education in the last decade, the amount of EOL content in nurse education remains inadequate. Drawing on literature mainly from the UK and USA, this review explores from the perspectives of students, newly qualified nurses, patients and carers the outcomes of EOL education. It reviews the evidence to determine whether newly qualified nurses are adequately prepared to deliver quality care to patients at the end of their lives. The evidence suggests that despite a greater emphasis on EOL care in nurse training, adequately preparing nurses remains a challenge to educators.

Part 2: Home-based family caregiving at the end of life: a comprehensive review of published qualitative research (1998-2008)

Family caregivers are crucial for supporting home death. We reviewed published qualitative research on home-based family caregiving at end of life (1998-2008), synthesizing key findings and identifying gaps where additional research is needed. Multiple databases were searched and abstracts reviewed for a focus on family caregiving and palliative care; full articles were reviewed to extract data for this review. In total, 105 articles were included. Findings are presented in the following areas: the caregiving experience and contextual features; supporting family caregivers at end of life; caregiving roles and decision-making; and rewards, meaning and coping. We noted a lack of definitional clarity; a reliance on interview methods and descriptive, thematic analyses, and a relative lack of diversity of patient conditions. Research needs are identified in several areas, including the bereavement experience, caregiver ambivalence, access to services, caregiver meaning-making, and relational and contextual influences on family caregiving at end of life.

Health-related quality of life as a valid outcome in the treatment of advanced colorectal cancer

With the recent trend of improved survival, there has been a marked interest in reviewing and refining the contribution of health related quality of life (HRQoL) outcome measures of treatment in advanced colorectal cancer. However, if HRQoL data are going to be of clinical value and help both physicians and patients make decisions there is a need for a consensus on both the design and methods of measurement of HRQoL in clinical trials, and an acknowledgement of the interpretation of the outcomes in clinical practice. Whilst it is encouraging to find that the quality of HRQoL measurement in clinical research has improved significantly over the last fifteen years, with a growing number of trial-based HRQoL studies, there is still the potential to improve the use of HRQoL in clinical decision making in advanced colorectal cancer. There is also the need to further refine measurement of HRQoL to provide useful data specific to these patients. It is anticipated that developments such as the liver metastases module EORTC (QLQ-LMC21) questionnaire will increase the sensitivity to change of the generic cancer measure, the EORTC QLQ-C30 and will provide essential HRQoL information regarding the use of treatments in both the curative and palliative settings. Furthermore, easy to use simple tools such as the "minimum standard checklist for evaluating HRQoL outcomes in cancer clinical trials" might be of help in guiding investigators on the basis of minimum criteria.

A patient and carer survey in a community clinical nurse specialist service

The community clinical nurse specialist (CNS) team provides specialist palliative care to clients with cancer and non-malignant, life-limiting diseases in clients' homes, community hospitals, and residential and nursing homes. CNSs are based in health centres, community hospitals (geographically spread around the county) or at the local hospice. There has been no systematic review of patient and carer levels of satisfaction since the conception of the CNS service in 1984. Accredited as a nursing development unit (Flint and Wright, 2001) by Leeds University, the team has been encouraged to obtain service users' views. National guidelines in the UK (National Institute for Health and Clinical Excellence (NICE), 2004) also recommend that systems be put in place to enable clients to make their voices heard in a variety of ways. The principle aim was to identify the level of patient and carer satisfaction and to highlight aspects of care that warranted alteration or improvement. The CNS team were also keen to identify the aspects of their role most helpful to patients and carers, enabling CNSs to spend their time in a way that is most beneficial to clients.

Key challenges and ways forward in researching the "good death": qualitative in-depth interview and focus group study

OBJECTIVE

To understand key challenges in researching end of life issues and identify ways of overcoming these.

DESIGN

Qualitative study involving in-depth interviews with researchers and focus groups with people affected by cancer.

PARTICIPANTS

An international sample of 32 researchers; seven patients with experience of cancer; and four carers in south east Scotland.

RESULTS

Researchers highlighted the difficulty of defining the end of life, overprotective gatekeeping by ethics committees and clinical staff, the need to factor in high attrition rates associated with deterioration or death, and managing the emotions of participants and research staff. People affected by cancer and researchers suggested that many people nearing the end of life do want to be offered the chance to participate in research, provided it is conducted sensitively. Although such research can be demanding, most researchers believed it to be no more problematic than many other areas of research and that the challenges identified can be overcome.

CONCLUSIONS

The continuing taboos around death and dying act as barriers to the commissioning and conduct of end of life research. Some people facing death, however, may want to participate in research and should be allowed to do so. Ethics committees and clinical staff must balance understandable concern about non-maleficence with the right of people with advanced illness to participate in research. Despite the inherent difficulties, end of life research can be conducted with ethical and methodological rigour. Adequate psychological support must be provided for participants, researchers, and transcribers.

Hospice at home service: the carer's perspective

GOALS OF THE WORK

The aim of this study was to explore the bereaved caregivers' experience of the Hospice at Home service delivered in one region of the UK.

MATERIALS AND METHODS

Three hundred and ten bereaved caregivers identified by the Community Specialist Palliative Care Team or Hospice at Home nurse, who met inclusion criteria, were sent a postal questionnaire to explore their views and experiences of the Hospice at Home service. Data were collected during 2002.

MAIN RESULTS

In total, 128 caregivers responded, providing a 41% response rate. Most caregivers believed that the Hospice at Home service enabled their loved one's wish to be cared for and to die at home to be fulfilled. A number of suggestions were made relating to increased awareness of the service, training for staff, coordination of service delivery and bereavement support.

CONCLUSIONS

The bereaved caregivers were thankful for the Hospice at Home service; however, the need for practical support, increased awareness of the Hospice at Home service and bereavement support were also identified. Although the bereaved caregivers provided a valuable insight in evaluating service provision, it is acknowledged that some caregivers are often so grateful for the treatment and care received that they tend to forget or ignore their less pleasant experiences. Further research is therefore required using an in-depth qualitative approach investigating on the carers' views and experiences of accessing the Hospice at Home service.

Palliative care research protocols: a special case for ethical review?

Between October 2001 and May 2002 the Chairperson and Vice-Chairperson of each Multicentre Research Ethics Committee (MREC) in England, Wales and Scotland took part in a semi-structured interview to ascertain the attitudes of MRECs to palliative care research. Interviews were transcribed and analysed using a grounded theory approach. Most respondents said each protocol was reviewed on its own merits, according to broad ethical principles, but were equivocal as to whether palliative care protocols posed particular or different challenges compared to those from other specialties. Respondents said they reviewed only a small number of palliative care protocols, and that they were less experienced with some of the study methods utilized, particularly qualitative designs. Four main themes emerged from the analysis. Respondents expressed concerns about the protocol itself--in regard to safeguarding the principles of autonomy and justice. There were concerns about how the research would be carried out, especially the protection of patients and the influence and input of the researcher in the process. The third theme concerned the impact of the research on the participant, particularly intrusion, potential distress and the existence of support mechanisms. Fourthly, respondents identified patient groups receiving palliative care (children, the elderly, bereaved families, patients in intensive therapy units, and those from ethnic groupings), who they considered might be particularly vulnerable.

Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity

This paper reports on a grounded theory interview-based study with 13 family members aged 28-80 years caring for terminally ill people at home (with a life expectancy of 3 months or less) in the Netherlands. The project was approved by the ethics committee of the Maastricht University Hospital. The aim of this study was to explore the experiences of family caregivers, their needs for home care, and which health services they receive. Data were analysed using the constant comparative method. 'Vulnerability' was identified as the core category. Caring for a terminally ill person at home requires continuous balancing between care burden and capacity to cope. Whether or not the carer will succeed in keeping in optimum balance is dependent on a number of factors impinging on the caregiver's vulnerability. Care burden, restricted activities, fear, insecurity, loneliness, facing death, lack of emotional, practical and information-related support were identified from the data as factors having the potential to increase the caregiver's vulnerability, and may be risk factors for fatigue and burnout. Continuing previous activities, hope, keeping control, satisfaction and good support are factors which may decrease the caregiver's vulnerability, and may protect against fatigue and burnout. The experiences of the caregivers in our study showed that the support from informal and professional caregivers was not sufficient. Education and practical tools may make professionals more sensitive for the vulnerable position of family caregivers, even when these caregivers do not show their vulnerability.

Community specialist palliative care: experiences of patients and carers

Specialist palliative care provides a range of services for patients and their carers who have complex needs. There is a need to identify what patients and carers gain from contact with the specialist palliative care nurse (SPCN) and what aspects of that care have a positive impact on their quality of life (QoL). The aims of the study were to gain insightful and credible accounts of participants' experiences of the SPCN; to consider those dimensions of care which impact on satisfaction; to discover whether the SPCN provides improvements in QoL and to explore whether experiences match expectations. A qualitative approach focused on the experience and individual meaning; it is the individual narratives produced by each participant that are the rich and interesting outcomes of this study. Both patients and carers reported satisfaction at being given time and being listened to, with the interviewees using words and phrases such as 'confidence', 'trust', knowledge', 'listens to' and 'a sense of being there'. The study shows the patient and carers' lack of knowledge about specialist palliative care while confirming the positive influence of the SPCN.

Patient and carer needs following a cancer-related hospital admission: the importance of referral to the district nursing service

BACKGROUND

Despite 30 years of research attention, discharge planning and district nurse (DN) referral remain problematic and few cancer-related publications exist. With shorter hospitalizations, discharged cancer patients and their carers may experience unmet needs for assessment, information and support. Although DN referral might enable patient/carer needs to be met, the DN role lacks clarity.

AIM

To investigate the needs of people with cancer, and their lay carers during discharge from hospital to home, and identify the role of DNs in meeting these needs.

METHOD

In this qualitative study, 71 pre- and postdischarge interviews were performed with cancer patients and (where possible) their carers. Predischarge interviews focused on expectations and postdischarge interviews on experiences of discharge and aftercare. Interview tapes were transcribed and analysed thematically.

RESULTS

Interviewees anticipated few aftercare needs during predischarge interviews but described met and unmet needs during postdischarge interviews. Unmet needs of those referred and not referred to the district nursing service were similar. Patients and carers had unmet needs for psychological support related to nutrition. Carers, especially those not resident with and not related to patients, had informational needs. Even very elderly, ill and isolated patients felt that other people had greater needs than their own and many thought that DNs only performed physical tasks.

CONCLUSION

All cancer patients discharged from hospital might be referred to a DN for ongoing assessment of needs. However, to ensure optimal results, the DN role needs to be clarified and public perceptions altered. Further research on psychological aspects of nutrition and the needs of carers not resident with/not related to patients is necessary.