Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence

AIM

This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations.

BACKGROUND

Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex.

DESIGN

A systematic review was conducted.

DATA SOURCES

Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis.

RESULTS

Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data.

CONCLUSION

The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

'Out of the frying pan into the fire': a qualitative study of the impact on masculinity for men living with advanced prostate cancer

Background

Studies have highlighted how advanced prostate cancer causes biographical disruption and presents challenges to masculine identities for men. This article draws on a wider study that focused on the experiences of men living with advanced prostate cancer and their caregivers. Although men's experience of advanced illness is not overlooked in the literature, only a small body of work has taken an in-depth look at men's experiences with advanced prostate cancer and their caregivers in a non-Westernised cultural and social context.

Objective

To explore how advanced prostate cancer impacts on men's masculine identity from the perspective of patients and their caregivers.

Methods

A qualitative study of men living with advanced prostate cancer (n = 23) and family caregivers (n = 23) in Ghana. We used the Consolidated Criteria for Reporting Qualitative Studies (COREQ) as the reporting guideline.

Results

The findings from this study highlight profound challenges for most men to their masculine identities, from both the treatment and the symptoms of advanced prostate cancer within a non-Westernised, patriarchal society. Four main themes were developed. These were the impact on masculinity in terms of: (1) physical changes, (2) sexual ability, (3) socio-economic roles and (4) expressing emotions. Changes in physical appearance, feeling belittled, having no active sexual life and the inability to continue acting as provider and protector of the family made some men describe their situation as one of moving out of the 'frying pan into the fire'.

Conclusion

This study revealed the impact of advanced prostate cancer on masculine identity. These narratives add a new dimension to what is already known about the impacts on men's masculine identities when dealing with advanced prostate cancer. This knowledge can help improve the care provided to men with advanced prostate cancer with emphasis on the cultures, beliefs and aspirations of these men and their caregivers.

The meaning of art in palliative care from the end users' perspective

BACKGROUND

Research concerning art initiatives within palliative care mainly addresses the artist's perspective. Our study brings in the end users' voices.

METHOD

We conducted ethnographic research in the framework of a program that invited professional artists to work at a Belgian palliative and supportive day care center. We examined how the so-called guests (i.e. end users) valued and experienced the artists' presence and activities.

RESULTS

Guests mentioned a positive influence on their personal and social well-being. They also indicated a cultural and artistic value. Art activities offered them something new and unexpected and took them to a different place. Guests felt challenged by activities when their well-being was negatively provoked, when they experienced activities as incomprehensible or in case of logistic hassle.

CONCLUSIONS

Art activities in palliative care settings must be adapted to the interests and abilities of the end users and supported by an educational and logistic framework.

'My wife is my doctor at home': A qualitative study exploring the challenges of home-based palliative care in a resource-poor setting

BACKGROUND

Family caregiving is common globally, but when a family member needs palliative and end-of-life care, this requires knowledge and expertise in dealing with symptoms, medication, and treatment side effects. Caring for a family member with advanced prostate cancer in the home presents practical and emotional challenges, especially in resource-poor contexts, where there are increasing palliative cases without adequate palliative care institutions.

AIM

The study explored palliative and end-of-life care experiences of family caregivers and patients living at home in a resource-poor context in Ghana.

DESIGN

This is a qualitative study using thematic analysis of face-to-face interviews at two-time points.

PARTICIPANTS

Men living with advanced prostate cancer (n = 23), family caregivers (n = 23), healthcare professionals (n = 12).

FINDINGS

Men with advanced prostate cancer face complex issues, including lack of access to professional care and a lack of resources for homecare. Family caregivers do not have easy access to professional support; they often have limited knowledge of disease progression. Patients have inadequate access to medication and other practical resources for homecare. Caregivers may be overburdened and perform the role of the patient's 'doctor' at home-assessing patient's symptoms, administering drugs, and providing hands-on care.

CONCLUSION

Home-based care is promoted as an ideal and cost-effective model of care, particularly in Westernised palliative care models. However, in resource-poor contexts, there are significant challenges associated with the implementation of this model. This study revealed the scale of challenges family caregivers, who lack basic training on aspects of caring, face in providing home care unsupported by healthcare professionals.

Exploring end-of-life care for South Asian kidney patients: interviewer reflections

The reduction of inequalities in access to quality care has been a central tenet of UK health policy. Ethnic minorities may experience additional inequalities because of language and other cultural barriers. This article reports interviewer reflections of conducting interviews with South Asian kidney patients about their experiences of end-of-life care. It explores themes which emerged from the analysis of a focus group held with eight bilingual research interviewers. The relevance of these themes to understanding inequalities and access to end-of-life care is discussed; together with the potential for the research process to contribute to service improvement.

The potential therapeutic value for bereaved relatives participating in research: An exploratory study

OBJECTIVE

Conducting research with the bereaved presents an immediate ethical challenge, as they are undoubtedly a vulnerable group, associated with high levels of distress and susceptible to both physical and mental health issues. A comprehensive understanding of the potential therapeutic benefits for bereaved relatives participating in palliative care research is limited, and therefore the ethics of engaging this group remain questionable.

METHOD

This paper describes a secondary analysis of qualitative data collected in the Care of the Dying Evaluation (CODE) project, examining the experiences of patients who died at home. It explores the motivations and potential benefits for bereaved relatives participating in research with reference to the recently developed concepts in bereavement theory. Cognitive interviews were conducted with 15 bereaved relatives and secondary analysis using a content analysis framework was employed to classify the data.

RESULTS

The results center around six recurring concepts identified as adaptive in current bereavement theory: an opportunity to share the narrative accounts of the final hours of their relative's life; a search for sense and meaning in loss; an ongoing bond/attachment with the deceased; altruistic motivations; oscillation between loss and restorative orientations; and a sense of resilience. Overall, the participants found that taking part in the research was valuable and that it could be described as offering therapeutic benefits.

SIGNIFICANCE OF RESULTS

The need for bereaved relatives to take part in research studies should be encouraged, as they provide an accurate proxy for the patient's experience of end-of-life care while also providing a valuable account of their own perspective as family member and carer. In addition, we highlight the need for ethics committees to be aware of the potential benefits for bereaved relatives participating in research of this kind.

Data analysis methods for assessing palliative care interventions in one-group pre-post studies

Objectives:

Studies of palliative care are often performed using single-arm pre–post study designs that lack causal inference. Thus, in this study, we propose a novel data analysis approach that incorporates risk factors from single-arm studies instead of using paired t-tests to assess intervention effects.

Methods:

Physical, psychological and social evaluations of eligible cancer inpatients were conducted by a hospital-based palliative care team. Quality of life was assessed at baseline and after 7 days of symptomatic treatment using the European Organization for Research and Treatment of Cancer QLQ-C15-PAL. Among 35 patients, 9 were discharged within 1 week and 26 were included in analyses. Structural equation models with observed measurements were applied to estimate direct and indirect intervention effects and simultaneously consider risk factors.

Results:

Parameters were estimated using full models that included associations among covariates and reduced models that excluded covariates with small effects. The total effect was calculated as the sum of intervention and covariate effects and was equal to the mean of the difference (0.513) between pre- and post-intervention quality of life (reduced model intervention effect, 14.749; 95% confidence intervals, −4.407 and 33.905; p = 0.131; covariate effect, −14.236; 95% confidence interval, −33.708 and 5.236; p = 0.152).

Conclusion:

Using the present analytical method for single-arm pre–post study designs, factors that modulate effects of interventions were modelled, and intervention and covariate effects were distinguished based on structural equation model.

Conducting research interviews with bereaved family carers: when do we ask?

BACKGROUND

Interviews with bereaved family carers to examine the end-of-life experience of the deceased are important tools for palliative care researchers, but the ethics of approaching the bereaved when they are grieving and vulnerable is often debated.

OBJECTIVE

The aim of this study was to explore the insights of bereaved family carers about the most appropriate time to be involved in a research interview about the end of life and death of their family member.

METHODS

This qualitative study used a social constructionist framework. Twenty-two bereaved family carers of people with motor neurone disease (MND) and cancer were interviewed in Western Australia.

RESULTS

Most family carers (86%) feel comfortable being interviewed about the death of their family member within the first 5 months of bereavement, with 43% reporting they could be interviewed within weeks after death. Family carers reported that recall would be better earlier in bereavement and felt it may be helpful to them to talk about their experiences earlier. They said bereaved people should be allowed to decide for themselves when to be involved in an interview.

CONCLUSIONS

These findings indicate that interviews with the bereaved may be most fruitful for researchers and beneficial to family carers when they are allowed to make the choice about timing for themselves, beginning weeks after the death of their family member.

Patient, caregiver, health professional and researcher views and experiences of participating in research at the end of life: a critical interpretive synthesis of the literature

Background

The development of the evidence-base informing end of life (EoL) care is hampered by the assumption that patients at the EoL are too vulnerable to participate in research. This study aims to systematically and critically review the evidence regarding the experiences and views of patients, caregivers, professionals and researchers about participation in EoL care research, and to identify best practices in research participation.

Methods

We searched seven electronic databases, and hand searched three journals and the bibliographies of relevant papers. Inclusion criteria were original research papers on involvement in EoL care research or its impact on participants. Critical interpretive synthesis was used to integrate the whole body of empirical evidence on this topic and generate theoretical categories from the evidence.

Results

Of a total of 239 identified studies, 20 studies met the inclusion criteria, from: the US (11), the UK (6) and Australia (3). Most focused on patients with cancer (12) and were conducted in hospices (9) or hospitals (7). Studies enquired about issues related to: EoL care research in general (5), specific research methods (13), and trial research (2). The studies evaluating willingness to participate in EoL care research showed positive outcomes across the different parties involved in research. Factors influencing willingness were mainly physical and cognitive impairment. Participating in research was a positive experience for most patients and carers but a minority experienced distress. This was related to: characteristics of the participants; the type of research; or the way it was conducted. Participatory study designs were found particularly suitable for enabling the inclusion of a wide range of participants.

Conclusion

The evidence explored within this study demonstrates that the ethical concerns regarding patient participation in EoL care research are often unjustified. However, research studies in EoL care require careful design and execution that incorporates sensitivity to participants’ needs and concerns to enable their participation. An innovative conceptual model for research participation relevant for potentially vulnerable people was developed.

Designing Research With Hospice and Palliative Care Populations

Research in palliative care and hospice populations is important for improving quality of care, quality of life, and provider understanding of individuals at the end of life. However, this research involves many potential challenges. This review seeks to inform and assist researchers targeting to design studies targeting hospice and palliative care patients by presenting a thorough review of the published literature. This review covers English-language articles published from 1990 through 2009 listed in the PsycInfo, Medline, or CINAHL research databases under relevant keywords. Articles on pediatric hospice were not included. Issues discussed include study design, informed consent, and recruitment for participants. Synthesized recommendations for researchers in these populations are presented.

Interviews on end-of-life care with older people: reflections on six european studies

Qualitative research provides important insights into the experiences and perspectives of older people on end-of-life issues, but such research is methodologically and ethically complex. We offer a set of reflections from six end-of-life care studies conducted with older people in four European countries: Belgium, Germany, the Netherlands, and the United Kingdom. The reflection process was informed by four full-day meetings between the authors and referral to sources including the study interview guides, summary "pen portraits" about key issues encountered in the interviews, and key sections of the interview transcripts. We identified as major challenges accessing people, the introduction of end-of-life issues in an interview, managing emotions, the presence of companions, and reciprocity. Formal ethical review committees rarely take into account these complex issues. We concluded that is it necessary to maintain an ongoing reflexive stance to enhance qualitative research practice in the intersecting fields of aging and end-of-life studies.

Palliative care clinical trials: how nurses are contributing to integrated, evidence-based care

The aim of this paper is to describe the emerging role of the palliative care clinical trials nurse in an era of evidence-based practice and increasing clinical trial activity in palliative care settings across Australia. An overview of the current clinical trials work is provided, with a focus on three aspects of clinical trials nursing practice that have significant implications for patients: managing the consent process, integrating clinical trials into multidisciplinary care, and establishing and building the evidence base to inform practice in palliative care settings. Clinical trials roles provide palliative care nurses with an opportunity to contribute to clinical research, help expand palliative care's evidence base, and develop their own research capabilities.

Review: a narrative review of the published ethical debates in palliative care research and an assessment of their adequacy to inform research governance

The quality of research, and the resulting quality of evidence available to guide palliative care, is dependent on the ethical decisions underpinning its design, conduct and report. Whilst much has been published debating the ethics of palliative care research, an assessment of the quality and synthesis of the central debates is not available. Such a review is timely to inform research governance. The methodology of this study is based on the principles of systematic reviews. Fifty-seven papers were reviewed following a thorough search, and were critically appraised for their literary quality, the knowledge on which they drew and the research standards they addressed. The debates identified address vulnerability, moral appropriateness, consent, gate-keeping and inclusion and research culture. The quality of debate and the sources of knowledge varied. The debate was rich in quality and knowledge with respect to the protection of the dignity, rights and safety of research participants, but less developed in relation to those of researchers and other staff. There is also little debate about the ethics of reporting of research and the ethics underpinning research leadership. A framework is offered that reconciles the ethical issues raised with potential methodological strategies identified from the review.