Implementation of a digital distress detection system in palliative care: qualitative data on perspectives of a multiprofessional palliative care team

BACKGROUND

Digital health technologies such as sensor systems are intended to support healthcare staff in providing adequate patient care. In the Department of Palliative Medicine (University Medical Center Freiburg), we developed and implemented a noninvasive, bed-based sensor system in a pilot study. The aim was to detect distress in patients who were no longer able to express themselves by monitoring heart and respiratory rates, vocalizations, and movement measurements. The sensor system was intended to supplement standard care, which generally cannot guarantee constant monitoring. As there is a lack of data on how healthcare professionals experience such a techno-digital innovation, the aim of this study was to explore how the multiprofessional palliative care team who piloted the sensor system perceived its potential benefits and limitations, and how they experienced the broader context of healthcare technology and research in palliative care.

METHODS

We conducted a qualitative interview study with 20 members of the palliative care team and analyzed the recorded, verbatim transcribed interviews using qualitative content analysis.

RESULTS

The sensor system was described as easy to use and as helpful support for patients, care staff, and relatives, especially against the backdrop of demographic change. However, it could not replace human interpretation of stress and subsequent treatment decisions: this remained the expertise of the nursing staff. A potential reduction in personnel was expected to be a risk of a digital monitoring system. The special conditions of research and digital health technologies in an end-of-life context also became clear. Specifically, healthcare staff were open to health technologies if they benefited the patient and were compatible with professional nursing and/or palliative care attitudes. Additionally, a patient-protective attitude and possible interprofessional differences in priorities and the resulting challenges for the team became apparent.

CONCLUSIONS

A potential digital solution for distress monitoring was considered useful by palliative care practitioners. However, interprofessional differences and compatibility with existing palliative care practices need to be considered before implementing such a system. To increase user acceptability, the perspectives of healthcare professionals should be included in the implementation of technological innovations in palliative care.

The 'work' of managing medications when someone is seriously ill and dying at home: A longitudinal qualitative case study of patient and family perspectives'

BACKGROUND

Managing medications can impose difficulties for patients and families which may intensify towards the end of life. Family caregivers are often assumed to be willing and able to support patients with medications, yet little is known about the challenges they experience or how they cope with these.

AIM

To explore patient and family caregivers' views of managing medications when someone is seriously ill and dying at home.

DESIGN

A qualitative design underpinned by a social constructionist perspective involving interviews with bereaved family caregivers, patients and current family caregivers. A thematic analysis was undertaken.

SETTING/PARTICIPANTS

Two English counties. Data reported in this paper were generated across two data sets using: (1) Interviews with bereaved family caregivers (n = 21) of patients who had been cared for at home during the last 6 months of life. (2) Interviews (n = 43) included within longitudinal family focused case studies (n = 20) with patients and current family caregivers followed-up over 4 months.

RESULTS

The 'work of managing medications' was identified as a central theme across the two data sets, with further subthemes of practical, physical, emotional and knowledge-based work. These are discussed by drawing together ideas of illness work, and how the management of medications can substantially add to the burden placed on patients and families.

CONCLUSIONS

It is essential to consider the limits of what it is reasonable to ask patients and families to do, especially when fatigued, distressed and under pressure. Focus should be on improving support via greater professional understanding of the work needed to manage medications at home.

Winners and Losers in Palliative Care Service Delivery: Time for a Public Health Approach to Palliative and End of Life Care

Background: Consumer experience of palliative care has been inconsistently and selectively investigated. Methods: People in Western Australia who had experienced a life limiting illness in the past five years were recruited via social media and care organisations (2020) and invited to complete a cross sectional consumer survey on their experiences of the care they received. Results: 353 bereaved carers, current carers and patients responded. The winners, those who received the best quality end-of-life care, were those who were aware of palliative care as an end-of-life care (EOLC) option, qualified for admission to and were able to access a specialist palliative care program, and with mainly a cancer diagnosis. The losers, those who received end-of-life care that was adequate rather than best practice, were those who were unaware of palliative care as an EOLC option or did not qualify for or were unable to access specialist palliative care and had mainly a non-cancer diagnosis. Both groups were well supported throughout their illness by family and a wider social network. However, their family carers were not adequately supported by health services during caregiving and bereavement. Conclusions: A public health approach to palliative and end of life care is proposed to integrate tertiary, primary, and community services through active consumer engagement in the design and delivery of care. Therefore, suggested strategies may also have relevance in many other international settings.

A co-designed framework to support and sustain patient and family engagement in health-care decision making

Background

Patient and family engagement in health care has emerged as a critical priority. Understanding engagement, from the perspective of the patient and family member, coupled with an awareness of how patient and family members are motivated to be involved, is an important component in increasing the effectiveness of patient engagement initiatives. The purpose of this research was to co‐design a patient and family engagement framework.

Methods

Workshops were held to provide additional context to the findings from a survey. Participants were recruited using a convenience sampling strategy. Workshop data collected were analysed using a modified constant comparative technique. The core research team participated in a workshop to review the findings from multiple inputs to inform the final framework and participated in a face validity exercise to determine that the components of the framework measured what they were intended to measure.

Results

The framework is organized into three phases of engagement: why I got involved; why I continue to be involved; and what I need to strengthen my involvement. The final framework describes seven motivations and 24 statements, arranged by the three phases of engagement.

Conclusion

The results of this research describe the motivations of patient and family members who are involved with health systems in various roles including as patient advisors. A deeper knowledge of patient and family motivations will not only create meaningful engagement opportunities but will also enable health organizations to gain from the voice and experience of these individuals, thereby enhancing the quality and sustainability of patient and family involvement.

Patient and carer involvement in palliative care research: An integrative qualitative evidence synthesis review

BACKGROUND

Patient/carer involvement in palliative care research has been reported as complex, difficult and less advanced compared to other areas of health and social care research. There is seemingly limited evidence on impact and effectiveness.

AIM

To examine the evidence regarding patient/carer involvement in palliative care research and identify the facilitators, barriers, impacts and gaps in the evidence base.

DESIGN

Qualitative evidence synthesis using an integrative review approach and thematic analysis.

DATA SOURCES

Electronic databases were searched up to March 2018. Additional methods included searching websites and ongoing/unpublished studies, author searching and contacting experts. Eligibility criteria were based on the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) framework. Two quality assessments on methodology and involvement were undertaken.

RESULTS

A total of 93 records were included. Eight main themes were identified, mainly concerning facilitators and barriers to effective patient and carer involvement in palliative care research: definitions/roles, values/principles, organisations/culture, training/support, networking/groups, perspectives/diversity, relationships/communication and emotions/impact. Evidence on the impact of involvement was limited, but when carried out effectively, involvement brought positive benefits for all concerned, improving the relevance and quality of research. Evidence gaps were found in non-cancer populations and collaborative/user-led involvement.

CONCLUSION

Evidence identified suggests that involvement in palliative care research is challenging, but not dissimilar to that elsewhere. The facilitators and barriers identified relate mainly to the conduct of researchers at an individual level; in particular, there exists a reluctance among professionals to undertake involvement, and myths still perpetuate that patients/carers do not want to be involved. A developed infrastructure, more involvement-friendly organisational cultures and a strengthening of the evidence base would also be beneficial.

Engaging patients throughout the health system: A landscape analysis of cold-call policies and recommendations for future policy change

Healthcare institutions may often prohibit “cold-calling” or direct contact with a potential research participant when the person initiating contact is unknown to the patient. This policy aims to maintain patient privacy, but may have unintended consequences as a result of physician gatekeeping. In this review, we discuss recruitment policies at the top academic institutions. We propose an ethical framework for evaluating cold-call policies based on three principles of research ethics. In order to maximize engagement of potential research participants, while maintaining patient privacy and autonomy, we then propose several alternative solutions to restrictive cold-call policies, including opt-in or opt-out platforms, a team-based approach, electronic solutions, and best practices for recruitment. As healthcare has evolved with more collaborative, patient-centered, data-driven care, the engagement of potential research participants should similarly evolve.

Dying persons' perspectives on, or experiences of, participating in research: An integrative review

BACKGROUND

Conducting research with dying persons can be controversial and challenging due to concerns for the vulnerability of the dying and the potential burden on those who participate with the possibility of little benefit.

AIM

To conduct an integrative review to answer the question 'What are dying persons' perspectives or experiences of participating in research?

DESIGN

A structured integrative review of the empirical literature was undertaken.

DATA SOURCES

Cumulative Index Nursing and Allied Health Complete, PsycINFO, MEDLINE, Informit and Embase databases were searched for the empirical literature published since inception of the databases until February 2017.

RESULTS

From 2369 references, 10 papers were included in the review. Six were qualitative studies, and the remaining four were quantitative. Analysis revealed four themes: value of research, desire to help, expression of self and participation preferences. Dying persons value research participation, regarding their contribution as important, particularly if it provides an opportunity to help others. Participants perceived that the potential benefits of research can and should be measured in ways other than life prolongation or cure. Willingness to participate is influenced by study type or feature and degree of inconvenience.

CONCLUSION

Understanding dying persons' perspectives of research participation will enhance future care of dying persons. It is essential that researchers do not exclude dying persons from clinically relevant research due to their prognosis, fear or burden or perceived vulnerability. The dying should be afforded the opportunity to participate in research with the knowledge it may contribute to science and understanding and improve the care and treatment of others.

A screening tool for predicting gatekeeping behaviour

AIM

To develop a typology and screening tool for gatekeeping behaviours by nurses responsible for recruitment in palliative care research.

DESIGN

Concurrent analysis.

METHOD

Two focus groups were conducted in 2015 with nine qualified hospice community nurses involved in recruitment to a trial in palliative care. The literature was searched for research into gatekeeping from 2000-2016. All narrative examples of gatekeeping activity were coded using gerunds. Common codes were then grouped and interpreted as a social process.

RESULTS

Gatekeeping is normal and should be expected. A continuum typology emerged, ranging from unintentional to active disengagement. Justification ranged from forgetting to deliberately not mentioning the study for fear of burdening patients. Viewing gatekeeping as a continuum allowed for the creation of a screening tool designed to collaboratively discuss and hence mitigate specific types of gatekeeping behaviour before they occur. This is a unique international contribution to this persistent issue.

Sense of Self in Alzheimer’s Research Participants

The sense of self is vulnerable in people with Alzheimer’s disease (AD), and might be positively and negatively influenced by research participation. The purpose of this study was to describe how people with AD express their experience of being a research participant with respect to their sense of self. Interviews and support group conversations involving 13 people with mild and moderate AD were analyzed using qualitative content analysis. Three themes were constructed: contributing to an important cause, gaining from participating, and experiencing risks and drawbacks. Participants described contributing to research as being in line with their lifelong values and lifestyles. They expressed contentment and pride about being research participants, emphasized their positive relationships with the researchers, and described participation as a meaningful activity. When research procedures threatened their sense of self, they were able to reason about risks and decline participation.

Impact on the individual: what do patients and carers gain, lose and expect from being involved in research?

BACKGROUND

Study feasibility and deliverability can benefit from involving patients and carers in the research process, known as patient and public involvement (PPI). There is less evidence on the experiences of patients and carers themselves and we require more information across a range of studies, health conditions and research stages.

AIMS

This study explored how patients and carers in eight diagnostic research specialties have been involved in research, their motivations and the impact involvement had on them.

METHOD

143 patients and carers across the Clinical Research Network (CRN) responded to an online semi-structured questionnaire (developed using participatory methodology). Quantitative and qualitative data were analysed.

RESULTS

A range of benefits were reported, including providing a life focus and an improved relationship with illness. Less positive experiences regarding time and money and lack of acknowledgement were also reported, along with suggestions for improvement.

CONCLUSIONS

PPI confers many benefits on patients and carers which could increase PPI recruitment if made explicit. More involvement in study recruitment and dissemination would increase the effectiveness of PPI input. Involving a more varied socioeconomic demographic and at an earlier stage is vital. Financial support for lower earners and greater feedback following involvement should also be explored.

Is the patient satisfaction questionnaire an acceptable tool for use in a hospice inpatient setting? A pilot study

Background

The Patient Satisfaction Questionnaire (PSQ) is an assessment tool used to evaluate patients’ perspectives of their doctor’s communication and interpersonal skills. The present pilot study investigated whether the PSQ could be administered successfully in a hospice inpatient setting and if it is an acceptable tool for completion by patients and relatives in this context.

Methods

The study was conducted in two phases. A first phase was undertaken to establish the process of PSQ administration in a hospice inpatient ward. A second phase of questionnaire administration followed by semi-structured interviews explored inpatient experiences of the questionnaire process.

Results

Overall, 30 inpatients and one relative were invited to complete the PSQ across both phases of data collection, representing 53% of all inpatients at the time of data collection. The remaining 47% were deemed unsuitable to ask due to a diagnosis of dying (24%), confusion (17%), distress (3%) or lack of availability (2%). The average response rate across both phases of data collection was 87%. Qualitative interview data suggested that the PSQ was considered clear, easy to understand and not burdensome in terms of time or effort for this population.

Conclusions

The PSQ appears an acceptable tool to use in a hospice inpatient setting. Many patients welcomed the opportunity to be involved and give feedback. Using a greater proportion of relatives as an alternative source of feedback could be considered in future studies.

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

Background

Improving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.

Aims

(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.

Design

A mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.

Results

Of the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.

Conclusions

Patients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

'It makes me feel that I'm still relevant': a qualitative study of the views of nursing home residents on dignity therapy and taking part in a phase II randomised controlled trial of a palliative care psychotherapy

BACKGROUND

Trials of dignity therapy (a palliative care psychotherapy) have shown self-reported benefits for participants from taking part, although more so in intervention than control groups. However, the sources of these benefits are unknown.

AIM

The aim of this study was to explore and compare participants' views on taking part in a mixed methods phase II randomised controlled trial of dignity therapy.

DESIGN

This was a qualitative study, using the framework approach to the analysis.

SETTING/PARTICIPANTS

It involved residents, aged 65+, with no major cognitive impairment, living in one of 15 nursing/care homes in London, UK (49 residents at 1-week follow-up, 36 residents at 8-week follow-up).

RESULTS

Residents' views were represented in nine themes, and three of these themes were evident only in the intervention group: views on the generativity document; generativity; and reminiscence. Six themes were evident in both groups: refocusing; making a contribution; interaction with the researcher or therapist; diversion; not helping with their problems; and cognitive impairment. Our findings support some of the proposed mechanisms of action for this palliative care intervention (pride, hopefulness, care tenor) but also draw attention to some of the potential problems of delivering the intervention. We show how residents could benefit from taking part in research, regardless of whether or not they receive the intended intervention.

CONCLUSIONS

Dignity therapy is likely to be beneficial to some care home residents, albeit the small minority who have the desire and the capacity to engage in such an intervention. Whether or not dignity therapy helps distressed residents, and the most effective way of screening for those who might benefit from it, need to be determined.