Journey of providing care in hospice: perspectives of occupational therapists

Occupational therapy in oncology palliative care for adolescents and young adults: Perspectives of Australian occupational therapists

INTRODUCTION

Palliative Care Australia suggests current needs (emotional wellbeing, understanding of cancers impact on relationships, everyday activities, and life milestones) for adolescent and young adults in palliative care are unmet due to a lack of age-specific palliative care facilities in Australia. This includes the provision of occupational therapy that can impact these unmet needs. Although the occupational therapy role in palliative care has been documented, little is known about existing occupational therapy services or occupational needs for young people with palliative care needs. The aims of this study were to obtain occupational therapists insights of working with this population in Australia regarding (1) gaps in palliative care services for this population; (2) facilitators and challenges to providing occupational therapy for this group; and (3) perceived occupational needs of young people living with a life-limiting cancer diagnosis.

METHODS

Using snowball sampling, an online survey was distributed to occupational therapists with experience working in palliative cancer care with adolescents and young adults. Available for 6 weeks, the survey included demographic, work history, and service delivery questions. Forced-choice questions were summarised descriptively, and content analysis was used to analyse free-text data.

RESULTS

Eleven completed surveys were returned. Overall, therapists perceived current palliative care services for this population within Australia to be lacking. Two gaps emerged: age-appropriate facilities and gaps in provision of psycho-social and occupational therapy services. Funding, lack of knowledge of the occupational therapy role, and professional confidence were highlighted as challenges to practice. Main occupational needs related to maintenance of as "normal" a life as possible: maintaining occupational role engagement, continuing connection with others, and being heard regarding their occupational needs.

CONCLUSION

Findings suggest a need for service changes, including custom-designed facilities, improved funding, training and mentoring, to support age-appropriate and occupation-focussed care for the young person in cancer-specific palliative care.

Cancer care and occupational therapy: A scoping review

INTRODUCTION

Cancer can disrupt participation in everyday activities, suggesting a place for occupational therapy; however, there is a need to articulate the nature, scope and available evidence supporting the occupational therapy role within cancer care. In this scoping review, we identify the breadth of practice and evidence for occupational therapy in cancer care, across all stages of the disease trajectory (diagnosis to palliation/survivorship) throughout the lifespan.

METHODS

Five electronic databases were searched in June 2018, for English language articles. Key words were: cancer care, OR oncolog*, OR oncologic care, OR neoplasms, OR cancer survivors, OR terminal cancer, OR cancer rehabilitation, AND occupational therap*. No date restrictions were imposed. Included were: all styles of literature including grey literature, all types of cancers and all age brackets. There were no restrictions on place of origin of papers. Following the Arksey and O'Malley (2006; International Journal of Social Research Methodology, 8: 19-32) framework for scoping reviews, the first author screened titles and abstracts, and all three authors reviewed sets of the included articles. Conflicts were discussed until consensus was reached.

RESULTS

After evaluating 305 titles and abstracts and 111 full-text articles, 89 papers were retained. Articles included research studies (n = 43), reviews (n = 15), grey literature (n = 16), practice analyses (n = 14) and an editorial (n = 1). The occupational therapy roles described were diverse, but largely descriptive in nature, with little evidence of outcomes from treatment. Furthermore, the majority of papers addressed adult populations, with few considering children, adolescents or young adults. Most papers focused on specific stages of the disease, and none addressed the disease along its full trajectory.

CONCLUSION

Despite identifying a diverse range of occupational therapy roles in cancer care throughout the disease trajectory and across the lifespan, the need for professional discourse and research within our profession was highlighted. This was particularly evident for adolescents and young adults with cancer.

Occupational engagement of people living with a life-limiting illness: Occupational therapists' perceptions

BACKGROUND/AIM

Occupational therapists working in palliative care aim to enable clients living with a life-limiting illness to continue participating in meaningful activities for as long as possible. However, little is published about the occupations people living with a life-limiting illness wish to engage in, and how occupational therapists can best enable occupational engagement. Therefore, this study aimed to gain an in-depth understanding of occupational therapists' perceptions on clients' occupational engagement post-diagnosis of a life-limiting condition.

METHODS

Occupational therapists working in Australia with people with a life-limiting illness were recruited to participate in a national online survey over the period of a month. Recruitment used a purposive, snowball sampling technique, resulting in 144 survey responses. Data were analysed using modified grounded theory methods.

RESULTS

Findings revealed two interrelated categories and four subcategories. The first category, focusing on life is concerned with therapists' perceptions of how clients continue to focus on living post diagnosis and encompasses two subcategories: (i) prioritised engagement and (ii) altered engagement. The second category, preparing for death, centres on therapists' perceptions of what clients do to practically prepare for death and find closure as their illness progresses, and is comprised of the two subcategories: (i) practical preparation for death and (ii) "facilitating closure".

CONCLUSION

Therapists perceived that meaningful occupational engagement changes over time as occupational performance levels decrease and clients prepare for death.

A model for occupation-based palliative care

This article presents a scoping review of 74 papers from the peer reviewed literature dealing with occupational therapy in palliative care. Five themes emerged regarding the parameters of occupational therapy in palliative care. The themes include: the importance of valued occupations even at the end of life, an exploration of how occupations change over the trajectory of a terminal illness, the balance between affirming life and preparing for death, valued occupations might be doing, being, becoming, or belonging occupations and the emphasis of a safe and supportive environment as an essential dimension for effective palliative care. These five themes are combined to form a model to guide occupational therapy in palliative care. The model offers structure and direction for occupational therapists in order to offer an opportunity for clients in palliative care to flourish toward the end of their lives.

An exploration of the lived experience of professional grief among occupational therapists working in palliative care settings

BACKGROUND/AIM

Occupational therapists who work in palliative care are frequently exposed to the experience of death and dying. Previous occupational therapy research has offered insight into factors that influence feelings relating to death and dying and associated coping strategies. However, existing literature is dated and has not specifically examined the concept of grief. This study addresses this gap in knowledge by exploring the lived experience of professional grief among occupational therapists working in palliative care settings.

METHODS

Semi-structured interviews were conducted with six Australian palliative care occupational therapists. The data were collected and analysed using an interpretive phenomenological approach.

RESULTS

Four interrelated themes were identified as core to the lived experience of professional grief among participants. These included; 'knowledge of self', 'giving permission for connections and feelings', 'filtering experience' and 'being present at work and at home'.

CONCLUSION

Considered in combination, these themes offer a guide for therapists to explore their own experience of and responses to professional grief and, in doing so, foster the development of personalised management strategies.

Who cares? A critical discussion of the value of caring from a patient and healthcare professional perspective

BACKGROUND

This study was undertaken in order to discover and illuminate the essential caring behaviours valued by both patients and staff in an orthopaedic setting within a district general hospital in the United Kingdom.

OBJECTIVES

This descriptive study was undertaken in order to acquire a greater understanding of perceptions of caring from both patient and orthopaedic healthcare professional perspectives.

METHODS

A sample of 30 patients and 53 healthcare professionals consisting of doctors, nurses, physiotherapists and occupational therapists were asked to complete the Caring Behaviours Inventory (CBI) questionnaire (Wolf et al., 1994). Data were analysed using descriptive and inferential statistics.

RESULTS

The findings revealed both similarities and differences relating to the importance of positive caring behaviours exhibited during caring interactions. Healthcare professionals working in the orthopaedic setting acknowledged the value of similar positive caring behaviours to those of the patient group but ranked the importance of these differently.

DISCUSSION

Several important insights into perceptions of caring have been gained. These relate to an overall understanding of the caring behaviours that are considered of importance to patients and healthcare professionals; the differences that exist between the caring perceptions of both groups and the factors which influence these perceptions.

A Qualitative Review of Occupational Therapists' Listening Behaviors and Experiences When Caring for Patients in Palliative or Hospice Care

Listening behaviors and experiences of occupational therapists working with patients in palliative or hospice care were investigated. Because the U.S. Government's Healthy People 2020 mandates better listening in health care, this research is timely. A qualitative design using semi-structured interviews and member checks provided researchers with rich text that revealed patterns and themes associated with listening behaviors, listening experiences, and listening training of occupational therapists working in palliative and hospice care. Participants were selected using typical case and snowball sampling. Six participants from two distinct geographic regions of the United States agreed to be interviewed. Interviews revealed four themes: working within the OT Practice Framework, key listening behaviors used in this context, listening barriers and challenges, and clinical competence and training needed prior to working with this population. This small sample size represents only a fraction of the occupational therapists working in palliative or hospice care, yet provides a foundation for further research and underscores the importance of listening behaviors.

A Phenomenological Inquiry into the Embodied Nature of Occupation at End of Life

Background. Occupational therapists propose that occupation is a basic human need across the lifespan. However, there is limited understanding of how occupation contributes to the end-of-life experience.

Purpose. The purpose of this study was to examine the embodied nature of occupation at end of life from the perspectives of Canadians 60 years of age or older who are diagnosed with a terminal illness.

Methods. The study adopted a phenomenological methodological approach to conduct semi-structured interviews with eight participants.

Findings. Six themes were identified. Participants described orientations toward occupations that involved: living with death, reworking everyday life, being guided by the will of the body, giving priority to relationships, attending to the small things, and engaging existential orientations.

Implications. This study contributes to knowledge about occupation at end of life and offers a starting point to guide practice that is attentive to the lived dimensions of occupation at end of life.

Has undergraduate education prepared occupational therapy students for possible practice in palliative care?

BACKGROUND

It has been argued that the unique nature of the occupational therapy role in palliative care (PC) warrants dedicated attention in undergraduate programmes to improve the confidence of occupational therapy graduates to work in this setting. Nevertheless, little is known about either the present PC education or the preparedness of graduates to work in this field. In addressing each of these issues, this study also sought information to guide the development of occupational therapy-specific undergraduate teaching resources.

METHODS

Survey information was gathered from two participant groups: (i) six occupational therapy schools from Australia and New Zealand and (ii) 24 occupational therapists employed in PC in Australia and New Zealand. Two different surveys were used, targeting issues specific to each of these two groups. Where possible, data were analysed quantitatively, whereas open-ended questions were interpreted thematically.

RESULTS

Occupational therapy schools reported 2-10 hours of PC-specific content and requested teaching resources specific to the occupational therapy role. Less than half of the clinicians (45.8%) recalled receiving undergraduate content in PC, and 75% reported having felt unprepared to work in this field. Clinicians who had received PC-specific content at university felt more prepared to work in this field than those who had not. Several recommendations for teaching PC were made.

CONCLUSIONS

The link between the extent of PC education received and perceived readiness to work in this field, together with the relatively small amount of dedicated undergraduate PC-specific content, supports the need to optimise teaching in this unique field.

Palliative care rehabilitation survey: a pilot study of patients' priorities for rehabilitation goals

Rehabilitation in palliative care is often overlooked. Settings that do consider occupational or physical therapy for palliative care patients often consult to therapists with competing caseloads. Few therapists specialise in palliative care, but nearly all ask, 'What needs doing'? and 'How well am I doing that'? No existing instruments address their questions. The objective is to develop and test a questionnaire for identifying patient goals and priorities for rehabilitation in palliative care. A questionnaire representing 11 domains of the Canadian Model of Occupational Performance was designed and pilot tested at four palliative care sites. Each question reflected a typical rehabilitation intervention in palliative care. Patients were asked to rate how important each of these interventions was on a numerical rating scale (0, not important-10, extremely important). Open-ended questions captured verbatim comments regarding thoughts of rehabilitation. The questionnaire was tested for test-retest reliability with two interviews approximately 1 week apart. Forty patients participated in the first interview and 32 in the second. Eight of eleven domain sub-scores achieved an intra-class correlation coefficient of 0.6 or higher. The highest means were for the physical (8.2), institutional (7.8) and self-care (7.8) domains on the first interview and for the spiritual domain (7.9) on the second interview. Suggestions are provided to shorten the questionnaire and strengthen validity. This work furthers the understanding of the role of rehabilitation in palliative care. It also illustrates the feasibility of involving palliative care patients in research that contributes to setting standards and measuring quality of service.

Living with dying: a hermeneutic phenomenological study of the work of hospice nurses

AIMS

(i) Explore the meaning of comfort care for hospice nurses. (ii) Provide an understanding of how this work is pursued in the hospice setting. (iii) Examine the means by which hospice nurses provide comfort to hospice patients.

BACKGROUND

The concepts of 'comfort' and 'comfort care' have long been a subject for examination by nurse researchers. The paper provides an overview of selected, relevant literature in this area. The methods used by nurse researchers have almost always been qualitative, and have focused on the meaning of nursing care for dying patients, from both nurses' and patients' perspectives.

DESIGN AND METHODS

The paper reports a hermeneutic phenomenological study of the work of 15 hospice nurses based in one hospice in the north of England. Sampling was purposive, and data were collected by means of semi-structured interviews. A reflective diary was also kept. The interpretation of data was guided by phenomenological and hermeneutic methodology.

RESULTS

The nurses interviewed spoke openly about their experiences of working with hospice patients. They saw the relief of suffering through 'comfort care' as an important element of their work. The findings are presented under three thematic headings: 'Comfort and relief', 'Peace and ease' and 'Spirituality and meaning'.

CONCLUSION

Hermeneutic phenomenology is an important method for uncovering the complex realities of nursing work. The nurses' perspectives on 'comfort care' they offer to patients were revealed by the data presented here, which were interpreted to offer a unique perspective on this type of nursing work.

RELEVANCE TO CLINICAL PRACTICE

These findings offer insights to nurses in both hospice and other settings; they give a number of perspectives on the nature of 'comfort care' and the meanings attached to it by experienced hospice nurses'.

An evaluation of the domiciliary occupational therapy service in palliative cancer care in a community trust: a patient and carers perspective

In the past 20 years there has been considerable growth in the provision of palliative care services. The shift in emphasis from hospice and hospital care to the development of community services has been significant. This enables people to be cared for at home and is in keeping with Government agenda. While this may be beneficial for the patient and fit in with the wishes of the family, it is likely to put heavy demands on the coping resources of individual carers. The views of service users are of paramount importance when discussing service evaluation and patient, family and carer empowerment. This research presents the findings of an evaluation of the domiciliary occupational therapy service provided for patients in the palliative stage of cancer care in North and West Belfast from the perspective of the patients and carers. For the purpose of this study, the palliative stage of cancer care is defined as the point from which the patient is no longer responsive to curative treatment, until death. A sample of 30 patients and their primary informal carers were selected using purposive sampling. A structured interview was carried out with both the patients and their carers to obtain views. Results suggest that although both patients and their carers value the service provided and report high levels of satisfaction, there are gaps identified in service provision and a lack of clear information among patients and their carers about the role of the occupational therapist and the range of services they can provide. There is a need to build upon the good work being done by domiciliary occupational therapists in the area of palliative cancer care and increase education and resources to ensure that a patient-centred, holistic, approach to care is used, addressing both the needs of the patient and their carers.

Role of the Speech-Language Pathologist in Palliative Hospice Care

In reviewing the literature, there are few articles describing the role of the speech-language pathologist in hospice. Communication impairments can impact upon the hospice team's ability to provide symptom control and supportive psychosocial care, and diminish the patient's ability to guide the decision making process and maintain social closeness with family. Swallowing difficulties may result in discomfort for patients and concern from caregivers. Patient care provided by the speech-language pathologist can align with the framework of the World Health Organization's components of palliative care. Four primary roles of the speech-language pathologist in hospice can be described. (1) To provide consultation to patients, families, and members of the hospice team in the areas of communication, cognition, and swallowing function; (2) To develop strategies in the area of communication skills in order to support the patient's role in decision making, to maintain social closeness, and to assist the client in fulfillment of end-of-life goals; (3) To assist in optimizing function related to dysphagia symptoms in order to improve patient comfort and eating satisfaction, and promote positive feeding interactions for family members and (4) To communicate with members of the interdisciplinary hospice team, to provide and receive input related to overall patient care. Further development of the speech-language pathologist as a participating member of the hospice interdisciplinary team would support the overall goal of providing quality care for patients and families served by hospice.