1
|
Herbst FA, Schneider N, Stiel S. Long-distance caregiving at the end of life: a protocol for an exploratory qualitative study in Germany. Palliat Care 2022; 21:69. [PMID: 35546403 PMCID: PMC9095417 DOI: 10.1186/s12904-022-00967-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Of the approximately 4.7 million people in Germany caring for a relative, many live at a geographical distance from their loved one. The provision of remote care to a terminally ill patient is associated with specific challenges and burdens. In the German context, research is lacking on the specific experiences and needs of caregivers in end-of-life situations who are geographically distanced from their relative. Thus, the overarching goal of the proposed study is to detail the specifics of long-distance caregiving at the end of life in Germany, determining the role played by physical distance in shaping end-of-life caregiving and identifying the needs of long-distance caregivers in this situation. Methods The exploratory qualitative study will be guided by an inductive logic, drawing on one-time semi-structured interviews. To uncover the multiplicity of caregiving experiences, long-distance caregivers of both patients receiving early palliative care and patients at a very advanced stage of disease will be included. The study will be divided into five phases: (1) preparation and pretest, (2) data collection and primary analysis, (3) data analysis and interpretation, (4) advisory board workshop and (5) conclusions and recommendations. Discussion The study will aim at generating valuable insight regarding the experiences and needs of family caregivers of end-of-life patients. This is particularly relevant, given that families are becoming increasingly geographically dispersed. As this trend continues, it will challenge traditional models of family care and shed light on novel caregiving issues that will need to be addressed through social and health policy. Trial registration The study was prospectively registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) (Registration N° DRKS00024164; date of registration: January 25, 2021), and is searchable under the International Clinical Trials Registry Platform Search Portal of the World Health Organization, under the German Clinical Trials Register number. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00967-8.
Collapse
Affiliation(s)
- Franziska A Herbst
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| |
Collapse
|
2
|
Stiel S, Krause O, Berndt CS, Ewertowski H, Müller-Mundt G, Schneider N. Caring for frail older patients in the last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care. Z Gerontol Geriatr 2019; 53:763-769. [PMID: 31828367 DOI: 10.1007/s00391-019-01668-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/22/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services. OBJECTIVE What are the challenges for GPs in caring for frail older patients at the end of their lives? MATERIAL AND METHODS A secondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over a period of 18 months with 14 family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory. RESULTS The results show that GPs see the care of frail older patients at the end of their lives through a) the growing number of older people, b) multimorbidity and complexity of the problem areas, c) the integration of geriatric and palliative approaches, d) the high average age of general practitioners and the lack of junior staff and e) the problem of ensuring care in rural areas as a major challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is a desire for more integration of both disciplines. CONCLUSION In this study GPs perceived a large overlap between geriatric and palliative care. Both approaches should be offered for a selection of patients as a combined service. In the future a systematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.
Collapse
Affiliation(s)
- Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany.
| | - Olaf Krause
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Carolin Sophie Berndt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Helen Ewertowski
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hanover, Germany
| |
Collapse
|
3
|
Pleschberger S, Reitinger E, Trukeschitz B, Wosko P. Older people living alone (OPLA) - non-kin-carers' support towards the end of life: qualitative longitudinal study protocol. BMC Geriatr 2019; 19:219. [PMID: 31409280 PMCID: PMC6692935 DOI: 10.1186/s12877-019-1243-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/06/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND A growing number of older people, mainly women, live in single households. They represent a vulnerable group as staying at home may turn out challenging when care needs increase, particularly at the end of life. Non-kin-carers can play an essential role in supporting individuals' preferences to stay at home. In research little attention has been paid to non-kin-carers, such as friends and neighbors, yet. Thus, the Older People Living Alone (OPLA) study will evaluate whether non-kin support is robust enough to enable care dependent people to stay at home even at the end of life. This paper aims to introduce the research protocol. METHODS We plan to apply a qualitative longitudinal study to better understand how older people living alone and their non-kin-carers manage to face the challenges with increased care needs towards the end-of-life. We will conduct serial interviews with the older persons living alone and their non-kin-carers. A total of 20-25 complete data sets and up to 200 personal interviews were planned. These will be complemented by regular telephone contacts. All interviews will be analysed following the grounded theory approach and strategies for reconstructing case trajectories, supported by MAXQDA software. In the course of the study, inter- and transdisciplinary workshops shall assure quality and support knowledge transfer. DISCUSSION This study protocol aims to guide research in a field that is difficult to approach, with regard to its topic, methodology and the interdisciplinary approach. As this study introduces longitudinal qualitative research methodology in the field of home care in Austria, a deeper understanding of (end-of-life-) care trajectories will be enhanced, which is of major relevance for future care planning. With investment in additional reflexivity and communication procedures innovative results and robust knowledge are expected outcomes.
Collapse
Affiliation(s)
- Sabine Pleschberger
- 0000 0004 0437 2768grid.502403.0Gesundheit Österreich GmbH (GÖG, Austrian Public Health Institute), Vienna, Austria
| | - Elisabeth Reitinger
- 0000 0001 2286 1424grid.10420.37Department of Nursing Science, University of Vienna, Vienna, Austria
| | - Birgit Trukeschitz
- 0000 0001 1177 4763grid.15788.33Research Institute for Economics of Aging, Vienna University of Economics and Business, Vienna, Austria
| | - Paulina Wosko
- 0000 0004 0437 2768grid.502403.0Gesundheit Österreich GmbH (GÖG, Austrian Public Health Institute), Vienna, Austria
| |
Collapse
|
4
|
Afshar K, Müller-Mundt G, van Baal K, Schrader S, Wiese B, Bleidorn J, Stiel S, Schneider N. Optimal care at the end of life (OPAL): study protocol of a prospective interventional mixed-methods study with pretest-posttest-design in a primary health care setting considering the view of general practitioners, relatives of deceased patients and health care stakeholders. BMC Health Serv Res 2019; 19:486. [PMID: 31307457 PMCID: PMC6631539 DOI: 10.1186/s12913-019-4321-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background At the end of life, about 85–90% of patients can be treated within primary palliative care (PC) provided by general practitioners (GPs). In Germany, there is no structured approach for the provision of PC by GPs including a systematic as well as timely identification of patients who might benefit from PC, yet. The project “Optimal care at the end of life” (OPAL) focusses on an improvement of primary PC for patients with both oncological and non-oncological chronic progressive diseases in their last phase of life provided by GPs and health care services. Methods OPAL will take place in Hameln-Pyrmont, a rural region in Lower Saxony, Germany. Target groups are (a) GPs, (b) relatives of deceased patients and (c) health care providers. The study follows a three-phase approach in a mixed-methods and pre-post design. In phase I (baseline, t0) we explore the usual practice of providing PC for patients with chronic progressive diseases by GPs and the collaboration with other health care providers. In phase II (intervention) the Supportive and Palliative Care Indicators Tool (SPICT) for the timely identification of patients who might benefit from PC will be implemented and tested in general practices. Furthermore, a public campaign will be started to inform stakeholders, to connect health care providers and to train change agents. In phase III (follow-up, t1) we investigate the potential effect of the intervention to evaluate differences in the provision of PC by GPs and to convey factors for the implementation of SPICT in general practices. Discussion The project OPAL is the first study to implement the SPICT-DE regionwide in general practices in Germany. The project OPAL may contribute to an overall optimisation of primary PC for patients in Germany by reducing GPs’ uncertainty in initiating PC, by consolidating their skills and competencies in identifying patients who might benefit from PC, and by improving the cooperation between GPs and different health care stakeholders. Trial registration The study was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; trial registration number: DRKS00015108; date of registration: 22th of January 2019).
Collapse
Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Katharina van Baal
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Sophie Schrader
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Jutta Bleidorn
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.,Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| |
Collapse
|
5
|
Afshar K, Feichtner A, Boyd K, Murray S, Jünger S, Wiese B, Schneider N, Müller-Mundt G. Systematic development and adjustment of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE). BMC Palliat Care 2018; 17:27. [PMID: 29454343 PMCID: PMC5816386 DOI: 10.1186/s12904-018-0283-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/06/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The Supportive and Palliative Care Indicators tool (SPICT) supports the identification of patients with potential palliative care (PC) needs. An Austrian-German expert group translated SPICT into German (SPICT-DE) in 2014. The aim of this study was the systematic development, refinement, and testing of SPICT-DE for its application in primary care (general practice). METHODS SPICT-DE was developed by a multiprofessional research team according to the TRAPD model: translation, review, adjudication, pretesting and documentation. In a pretest, five general practitioners (GPs) rated four case vignettes of patients with different PC needs. GPs were asked to assess whether each patient might benefit from PC or not (I) based on their subjective appraisal ("usual practice") and (II) by using SPICT-DE. After further refinement, two focus groups with 28 GPs (68% with a further qualification in PC) were conducted to test SPICT-DE. Again, participants rated two selected case vignettes (I) based on their subjective appraisal and (II) by using SPICT-DE. Afterwards, participants reflected the suitability of SPICT-DE for use in their daily practice routine within the German primary care system. Quantitative data were analysed with descriptive statistics and non-parametric tests for small samples. Qualitative data were analysed by conventional content analysis. Focus group discussion was analysed combining formal and conventional content analysis. RESULTS Compared to the spontaneous rating of the case vignettes based on subjective appraisal, participants in both the pretest and the focus groups considered PC more often as being beneficial for the patients described in the case vignettes when using SPICT-DE. Participants in the focus groups agreed that SPICT-DE includes all relevant indicators necessary for an adequate clinical identification of patients who might benefit from PC. CONCLUSIONS SPICT-DE supports the identification of patients who might benefit from PC and seems suitable for routine application in general practice in Germany. The systematic development, refinement, and testing of SPICT-DE in this study was successfully completed by using a multiprofessional and participatory approach.
Collapse
Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Angelika Feichtner
- Paracelsus Medical University Salzburg, Strubergasse 21, 5020 Salzburg, Austria
| | - Kirsty Boyd
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Scott Murray
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG UK
| | - Saskia Jünger
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health, University of Cologne, Albertus-Magnus-Platz, 50923 Cologne, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| |
Collapse
|
6
|
Fleming J, Calloway R, Perrels A, Farquhar M, Barclay S, Brayne C. Dying comfortably in very old age with or without dementia in different care settings - a representative "older old" population study. BMC Geriatr 2017; 17:222. [PMID: 28978301 PMCID: PMC5628473 DOI: 10.1186/s12877-017-0605-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/01/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Comfort is frequently ranked important for a good death. Although rising numbers of people are dying in very old age, many with dementia, little is known about symptom control for "older old" people or whether care in different settings enables them to die comfortably. This study aims to examine, in a population-representative sample, associations between factors potentially related to reported comfort during very old people's final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. METHODS Retrospective analyses linked three data sources for n = 180 deceased study participants (68% women) aged 79-107 in a representative population-based UK study, the Cambridge City over-75s Cohort (CC75C): i) prospective in-vivo dementia diagnoses and cognitive assessments, ii) certified place of death records, iii) data from interviews with relatives/close carers including symptoms and "How comfortable was he/she in his/her final illness?" RESULTS In the last year of life 83% were disabled in basic activities, 37% had moderate/severe dementia and 45% minimal/mild dementia or cognitive impairment. Regardless of dementia/cognitive status, three-quarters died following a final illness lasting a week or longer. 37%, 44%, 13% and 7% of the deceased were described as having been "very comfortable", "comfortable", "fairly comfortable" or "uncomfortable" respectively during their final illness, but reported symptoms were common: distress, pain, depression and delirium or confusion each affected 40-50%. For only 10% were no symptoms reported. There were ≥4-fold increased odds of dying comfortably associated with being in a care home during the final illness, dying in a care home, and with staying in place (dying at what death certificates record as "usual address"), whether home or care home, compared with hospital, but no significant association with disability or dementia/cognitive status, regardless of adjustment. CONCLUSIONS These findings are consistent with reports that care homes can provide care akin to hospice for the very old and support an approach of supporting residents to stay in their care home or own home if possible. Findings on reported high prevalence of multiple symptoms can inform policy and training to improve older old people's end-of-life care in all settings.
Collapse
Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Rowan Calloway
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- North East Thames Foundation School, London, UK
| | - Anouk Perrels
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Faculty of Medicine, Vrije Universiteit, Amsterdam, Netherlands
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| |
Collapse
|
7
|
Geiger K, Schneider N, Bleidorn J, Klindtworth K, Jünger S, Müller-Mundt G. Caring for frail older people in the last phase of life - the general practitioners' view. BMC Palliat Care 2016; 15:52. [PMID: 27255464 PMCID: PMC4890268 DOI: 10.1186/s12904-016-0124-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Frail older people are an increasingly important group in primary care due to demographic change. For these patients, a palliative care approach may be useful to sustain the quality of life in the last phase of their lives. While general practitioners (GPs) play a key role in the primary care for older patients, general palliative care is still in its infancy and little is known in Germany about caring for frail older people towards the end of life. This study aims to explore the tasks and challenges regarding the care for frail older patients in the last phase of life from the GPs' point of view, and the latter's perception of their own role and responsibilities. METHODS Explorative qualitative study based on semi-structured in-depth interviews with 14 GPs from urban and rural regions in Lower Saxony, Germany. Analysis was carried out according to the principles of Grounded Theory. RESULTS The GPs' key commitment "caring for frail older patients until the end" as an integral part of primary care was worked out as a key category, flanked by central issues: "causal conditions and challenges," which include patients' preconditions and care needs as well as communication and cooperation aspects on the carers' level. "Barriers and facilitators within the health system" refers to prerequisites of the German healthcare system, such as high caseloads. Regarding "strategies to comply with this commitment", various self-developed strategies for the care of frail older people are presented, depending on the GPs' understanding of their professional role and individual circumstances. CONCLUSIONS The GPs show a strong commitment to caring for the frail older patients until the end of life. However, it is a challenging and complex task that requires significant time, which can take GPs to their limits. There is a great need to improve patient-and family-centered proactive communication, as well as interprofessional cooperation. Strengthening the team approach in primary care could relieve the burden on GPs, especially in rural areas, while simultaneously improving end-of-life care for their patients.
Collapse
Affiliation(s)
- Karin Geiger
- Hannover Medical School, Institute of General Practice, Hannover, Germany
| | - Nils Schneider
- Hannover Medical School, Institute of General Practice, Hannover, Germany.
| | - Jutta Bleidorn
- Hannover Medical School, Institute of General Practice, Hannover, Germany
| | | | - Saskia Jünger
- Hannover Medical School, Institute of General Practice, Hannover, Germany
| | | |
Collapse
|
8
|
|
9
|
Klindtworth K, Geiger K, Pleschberger S, Bleidorn J, Schneider N, Müller-Mundt G. Leben und Sterben mit Gebrechlichkeit. Z Gerontol Geriatr 2016; 50:151-158. [DOI: 10.1007/s00391-015-1011-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/09/2015] [Accepted: 12/08/2015] [Indexed: 11/30/2022]
|
10
|
Alonso-Renedo FJ, González-Ercilla L, Iráizoz-Apezteguía I. [Advanced organ failure in the elderly. Some issues from a geriatrics, palliative medicine and bioethics perspectives]. Rev Esp Geriatr Gerontol 2014; 49:228-234. [PMID: 24387870 DOI: 10.1016/j.regg.2013.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 10/29/2013] [Accepted: 11/05/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To analyze the literature as regards the knowledge, skills and attitudes that these disciplines can provide in improving technical, ethical and human quality health care in the elderly with advanced organ failure, multimorbidity, frailty and progressive dementia. MATERIAL AND METHODS A comprehensive review focused on available references on the interrelationship between geriatric medicine and palliative medicine, education in bioethics, prognostic tools, functional status, and the humanization of health care. RESULTS Advance care planning, comprehensive geriatric assessment, the study of the values of the patient and their introduction in decision-making process, as well as the need to promote moral, care, and healthcare organizational ethics, are essential elements to achieve this objective. CONCLUSIONS Practitioners and healthcare organizations should seek excellence as a moral requirement. To achieve this, there is a priority to acquire virtues of care and fundamental concepts of geriatric and palliative medicine, assessing functional status, advance care planning and patient/family needs as essential issues to protect, care for and promote them in all care settings.
Collapse
Affiliation(s)
| | - Leire González-Ercilla
- Servicios Sociales Aita Menni, Residencia Joxemiel Barandiaran, Durango, Vizcaya, España
| | | |
Collapse
|