Be known, be available, be mutual: a qualitative ethical analysis of social values in rural palliative care

"Stop Imposing on Us": A Critical Examination of Ethnocultural Considerations in the Canadian Volunteer Hospice Palliative Care Landscape

Volunteers are foundational in hospice programs. The purpose of this research was to address social, ethnic and demographic changes in Southwestern Ontario and understand how this may affect volunteer recruitment, and representation. Interviews and focus groups were conducted with hospice volunteers, key informants from leaders in ethnocultural communities, and hospice staff. Qualitative data from the interviews was analyzed using thematic analysis in five phases. Findings suggest ethnocultural interpretations of hospice can be very different than Westernized, Eurocentric ideas around end-of-life care. Systemic and structural barriers, information sharing, volunteer motivation and representation were found to influence and impact ethnocultural volunteer recruitment in hospice palliative care. Using a critical analysis allows us to identify the "imposition" of a Euro-ethnocentric hospice palliative care model that prevents recruitment of and impedes access of ethnocultural groups to hospice palliative care. To build bridges across predominantly White/Western models of care to ethnocultural racialized communities requires constant communication, relationship building, and determination in mutuality of learning on behalf of the dominant model. This research has implications for different regions of Canada providing hospice palliative care and hoping to increase ethnocultural accessibility and volunteer recruitment for hospice palliative care.

Post-death burial and funeral practices in rural Alberta

BACKGROUND

Burial and funeral practices are important customary mortuary rituals, especially in rural areas as people are likely to have different values and interests than people who live in larger cities. However, little is known about rural post-death practices in Canada.

AIMS

This review gathered information on funeral and burial practices in rural Alberta, a western Canadian province with a diverse rural population.

METHODS

A literature review of community print sources, including obituaries and funeral home websites, was conducted for select representative rural communities.

FINDINGS

This review found that cremations outnumber burials, and mortuary ceremonies more commonly occur in non-religious settings. Furthermore, personalised post-death rituals were identified as highly significant to rural people as they allow the dead to remain connected to their rural land, family and community.

CONCLUSION

It is important to understand rural mortuary rituals to help prepare dying rural people and their families.

Responding to Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote New South Wales

Ethical perspectives on regional, rural, and remote healthcare often, understandably and importantly, focus on inequities in access to services. In this commentary, we take the opportunity to examine the implications of normalizing metrocentric views, values, knowledge, and orientations, evidenced by the recent (2022) New South Wales inquiry into health outcomes and access to hospital and health services in regional, rural and remote New South Wales, for contemporary rural governance and justice debates. To do this, we draw on the feminist inspired approach to rural health ethics involving analysis of power relationships developed by Simpson and McDonald and related ideas from critical health sociology. In presenting this analysis, we extend contemporary thought about spatial health inequities and structural violence.

Scaling out a palliative compassionate community innovation: Nav-CARE

Background

There is an urgent need for community-based interventions that can be scaled up to meet the growing demand for palliative care. The purpose of this study was to scale out a volunteer navigation intervention called Nav-CARE by replicating the program in multiple contexts and evaluating feasibility, acceptability, sustainability, and impact.

Methods

This was a scale-out implementation and mixed-method evaluation study. Nav-CARE was implemented in 12 hospice and 3 nonhospice community-based organizations spanning five provinces in Canada. Volunteers visited clients in the home approximately every 2 weeks for 1 year with some modifications required by the COVID-19 public health restrictions. Qualitative evaluation data were collected from key informants (n = 26), clients/family caregivers (n = 57), and volunteers (n = 86) using semistructured interviews. Quantitative evaluation data included volunteer self-efficacy, satisfaction, and quality of life, and client engagement and quality of life.

Findings

Successful implementation was influenced by organizational capacity, stable and engaged leadership, a targeted client population, and skillful messaging. Recruitment of clients was the most significant barrier to implementation. Clients reported statistically significant improvements in feeling they had someone to turn to, knowing the services available to help them in their community, being involved in things that were important to them, and having confidence in taking care of their illness. Improvements in clients' quality of life were reported in the qualitative data, although no statistically significant gains were reported on the quality of life measure. Volunteers reported good self-efficacy and satisfaction in their role.

Conclusion

The feasibility, acceptability, and sustainability of the program were largely dependent on strong intraorganizational leadership. Volunteers reported that their involvement in Nav-CARE enabled them to engage in ongoing learning and have a meaningful and relational role with clients. Clients and families described the positive impact of a volunteer on their engagement and quality of life.

Cultural Considerations in Palliative Care Provision: A Scoping Review of Canadian Literature

Background: Palliative care, a division of health care that provides treatment to patients facing terminal or incurable illness, prioritizes maintaining quality of life for the patients it serves. Factors that influence quality of life are highly individualized, encompassing social, economic, or cultural determinants of health. In particular, cultural determinants remain an understudied element of palliative care.

Objectives: The purpose of this article is to identify key concepts and issues arising from offering culturally relevant palliative care by reviewing how the concept of culture has been discussed in Canadian palliative care literature.

Design: A scoping review of medical databases was conducted to identify recent Canadian literature connecting culture and palliative care provision. This review yielded 21 relevant results from the past 10 years.

Results: Ideas frequently mentioned in Canadian palliative care literature include cultural competency in health care providers, cultural sensitivity of treatment options, and cultural accessibility of available services. Issues that arose from the literature included differing ideas of the meanings of life and death, visibility of cultural minority groups, spiritual care needs, desire to involve friends and family in care, and misunderstandings of language and communication styles.

Conclusion: The results of this review provide a starting point from which health care providers can begin lending attention to cultural determinants of health, thus improving palliative care services for diverse populations.

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

BACKGROUND

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

AIM

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

DESIGN

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

DATA SOURCES

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

RESULTS

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

CONCLUSION

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

A mixed-method evaluation of a volunteer navigation intervention for older persons living with chronic illness (Nav-CARE): findings from a knowledge translation study

Background

Volunteer navigation is an innovative way to help older persons get connected to resources in their community that they may not know about or have difficulty accessing. Nav-CARE is an intervention in which volunteers, who are trained in navigation, provide services for older persons living at home with chronic illness to improve their quality of life. The goal of this study was to evaluate the impact of Nav-CARE on volunteers, older persons, and family participating across eight Canadian sites.

Methods

Nav-CARE was implemented using a knowledge translation approach in eight sites using a 12- or 18-month intervention period. A mixed method evaluation was used to understand the outcomes upon older person engagement; volunteer self-efficacy; and older person, family, and volunteer quality of life and satisfaction with the intervention.

Results

Older persons and family were highly satisfied with the intervention, citing benefits of social connection and support, help with negotiating the social aspects of healthcare, access to cost-effective resources, and family respite. They were less satisfied with the practical help available for transportation and errands. Older persons self-reported knowledge of the services available to them and confidence in making decisions about their healthcare showed statistically significant improvements (P < .05) over 12–18 months. Volunteers reported satisfaction with their role, particularly as it related to building relationships over time, and good self-efficacy. Volunteer attrition was a result of not recruiting older persons in a timely manner. There was no statistically significant improvement in quality of life for older persons, family or volunteers from baseline to study completion.

Conclusions

Findings from this study support a developing body of evidence showing the contributions volunteers make to enhanced older person and family well-being in the context of chronic illness. Statistically significant improvements were documented in aspects of client engagement. However, there were no statistically significant improvements in quality of life scores even though qualitative data illustrated very specific positive outcomes of the intervention. Similar findings in other volunteer-led intervention studies raise the question of whether there is a need for targeted volunteer-sensitive outcome measures.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12904-020-00666-2.

Shades of gray: Conscientious objection in medical assistance in dying

With the advent of legalized medical assistance in dying [MAiD] in Canada in 2016, nursing is facing intriguing new ethical and theoretical challenges. Among them is the concept of conscientious objection, which was built into the legislation as a safeguard to protect the rights of healthcare workers who feel they cannot participate in something that feels morally or ethically wrong. In this paper, we consider the ethical complexity that characterizes nurses' participation in MAiD and propose strategies to support nurses' moral reflection and imagination as they seek to make sense of their decision to participate or not. Deconstructing the multiple and sometimes conflicting ethical and professional obligations inherent in nursing in such a context, we consider ways in which nurses can sustain their role as critically reflective moral agents within a context of a relational practice, serving the diverse needs of patients, families, and communities, as Canadian society continues to evolve within this new way of engaging with matters of living and dying.

Funeral and interment practices of rural residents: A mixed methods study

There are few studies on interment preferences and practices for people in remote and rural regions of developed countries. This mixed methods study in rural Australia collated data on funeral and interment practices with an ethnographic exploration of the post-death preferences of terminally-ill rural residents. In the region, between February 2015 and May 2016, 44% of decedents were cremated. Burial preferences reflected family traditions, generational connections to historic cemeteries, and the wish to instantiate belonging to people and place. Cremation provided the opportunity for ashes to be scattered at personally-significant places. Funeral planning was important for patients and family caregivers, and funerals are valued rural community rituals.

Evaluating a model of delivering specialist palliative care services in rural New Zealand

INTRODUCTION Various methods of delivering specialist palliative care to rural areas have been discussed in the literature, but published evaluations of these models are sparse. This study surveyed the stakeholders of a rural specialist palliative care service (SPCS) to help identify potential gaps and inform planning regarding the future vision. METHODS A survey was sent to all relevant stakeholders across the West Coast of New Zealand, including staff in primary care, aged residential care and the hospital. It focused on understanding the local model of palliative care, the quality of the current service and perceived gaps. RESULTS Thirty-three per cent of the surveys were returned, from a cross-section of health-care providers. The medical respondents rated the quality of the service higher than nursing and allied health participants. All of the groups reported feeling the specialist palliative care team (SPCT) was under-resourced. Additional educational opportunities were considered essential. DISCUSSION Stakeholders found the service easy to access, but improvements in communication, educational opportunities and forward planning were identified as being needed. This information helps the West Coast SPCT plan its future direction and develop a higher-quality service that meets the needs of all stakeholders.

Rural end-of-life care from the experiences and perspectives of patients and family caregivers: A systematic literature review

BACKGROUND

End-of-life care must be relevant to the dying person and their family caregiver regardless of where they live. Rural areas are distinct and need special consideration. Gaining end-of-life care experiences and perspectives of rural patients and their family caregivers is needed to ensure optimal rural care.

AIMS

To describe end-of-life care experiences and perspectives of rural patients and their family caregivers, to identify facilitators and barriers to receiving end-of-life care in rural/remote settings and to describe the influence of rural place and culture on end-of-life care experiences.

DESIGN

A systematic literature review utilising the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Four databases (PubMed, CINAHL, Scopus and Web of Science) were searched in January 2016, using a date filter of January 2006 through January 2016; handsearching of included article references and six relevant journals; one author contacted; pre-defined search terms and inclusion criteria; and quality assessment by at least two authors.

RESULTS

A total of 27 articles (22 rural/remote studies) from developed and developing countries were included, reporting rural end-of-life care experiences and perspectives of patients and family caregivers. Greatest needs were informational (developed countries) and medications (developing countries). Influence of rural location included distances, inaccessibility to end-of-life care services, strong community support and importance of home and 'country'.

CONCLUSION

Articulation of the rural voice is increasing; however, there still remain limited published rural studies reporting on patient and family caregivers' experiences and perspectives on rural end-of-life care. Further research is encouraged, especially through national and international collaborative work.

Nurse-led navigation to provide early palliative care in rural areas: a pilot study

Background

Few services are available to support rural older adults living at home with advancing chronic illness. The objective of this project was to pilot a nurse-led navigation service to provide early palliative support for rural older adults and their families living at home with advancing chronic illness.

Methods

Twenty-five older adults and 11 family members living with advancing chronic illness received bi-weekly home visits by a nurse navigator over a 2-year period. Navigation services included symptom management, education, advance care planning, advocacy, mobilization of resources, and psychosocial support. The nurse navigator collected longitudinal data on older adult and family needs, and older adult quality of life and healthcare utilization.

Results

Satisfaction with the service was high. There was no attrition over the 2-year period except through death, and few cancelled visits, indicating a high degree of acceptability of the intervention. The navigator addressed complex, multi-faceted needs through connecting health, social, and informal community resources. Participants who indicated a preferred place of death were able to die in that preferred place (n = 7). Emergency room use by participants was minimal and largely unpreventable by the nurse navigator. Longitudinal health-related quality of life scores for many participants were poor, lending further support to the need for more focused attention to this upstream palliative population.

Conclusions

Using a nurse navigator to facilitate early palliative care for rural older adults living with advanced chronic illness is a promising innovation for meeting the needs of this population. Further research is required to evaluate outcomes on a larger scale.

Bereaved family members' perspectives on suffering among older rural cancer patients in palliative home nursing care: A qualitative study

Little is known about experiences with receiving home nursing care when old, living in a rural area, and suffering from end-stage cancer. The aim of this study was thus to investigate bereaved family members' perceptions of suffering by their older relatives when receiving palliative home nursing care. Qualitative semi-structured interviews were conducted with 10 family members, in Norway during autumn 2015, and directed content analysis guided by Katie Eriksson's theoretical framework on human suffering was performed upon the data. The two main categories identified reflected expressions of both suffering and well-being. Expressions of suffering were related to illness, to care and to life and supported the theory. Expressions of well-being were related to other people (e.g. familiar people and nurses), to home and to activity. The results indicate a need to review and possibly expand the perspective of what should motivate care. Nursing and palliative care that become purely disease and symptom-focused may end up with giving up and divert the attention to social and cultural factors that may contribute to well-being when cure is not the goal.

Factors affecting rural volunteering in palliative care - an integrated review

To review factors shaping volunteering in palliative care in Australian rural communities using Australian and International literature. Identify gaps in the palliative care literature and make recommendations for future research. A comprehensive literature search was conducted using Proquest, Scopus, Sage Premier, Wiley online, Ovid, Cochran, Google Scholar, CINAHL and Informit Health Collection. The literature was synthesised and presented in an integrated thematic narrative. Australian Rural communities. While Australia, Canada, the United States (US) and the United Kingdom (UK) are leaders in palliative care volunteer research, limited research specifically focuses on volunteers in rural communities with the least occurring in Australia. Several interrelated factors influence rural palliative care provision, in particular an increasingly ageing population which includes an ageing volunteer and health professional workforce. Also current and models of palliative care practice fail to recognise the innumerable variables between and within rural communities such as distance, isolation, lack of privacy, limited health care services and infrastructure, and workforce shortages. These issues impact palliative care provision and are significant for health professionals, volunteers, patients and caregivers. The three key themes of this integrated review include: (i) Geography, ageing rural populations in palliative care practice, (ii) Psychosocial impact of end-end-of life care in rural communities and (iii) Palliative care models of practice and volunteering in rural communities. The invisibility of volunteers in rural palliative care research is a concern in understanding the issues affecting the sustainability of quality palliative care provision in rural communities. Recommendations for future Australian research includes examination of the suitability of current models of palliative care practice in addressing the needs of rural communities; the recruitment, training, ongoing education and support of volunteers in rural palliative care provision to ensure equitable care for all communities in Australia regardless of location.

"Picking up the pieces" - Meanings of receiving home nursing care when being old and living with advanced cancer in a rural area

Rural home nursing care is a neglected area in the research of palliative care offered to older cancer patients. Because access to specialized services is hampered by long distances and fragmented infrastructure, palliative care is often provided through standard home nursing services and delivered by general district nurses. This study aimed to illuminate the lived experience and to interpret the meaning of receiving home nursing care when being old and living with advanced cancer in a rural area in Norway. Narrative interviews were conducted with nine older persons, and a phenomenological hermeneutic approach was used to interpret the meaning of the lived experience. The analysis revealed three themes, each with subthemes: being content with what one gets, falling into place, and losing one's place. The phrase picking up the pieces was found useful to sum up the meaning of this lived experience. The three respective themes refer to how the pieces symbolize the remaining parts of life or available services in their environment, and how the older persons may see themselves as pieces or bricks in a puzzle. A strong place attachment (physical insideness, social insideness, and autobiographical insideness) is demonstrated by the informants in this study and suggests that the rural context may provide an advantageous healthcare environment. Its potential to be a source of comfort, security, and identity concurs with cancer patients' strong desire for being seen as unique persons. The study shows that district nurses play an essential role in the provision of palliative care for older rural patients. However, the therapeutic value of being in one's familiar landscape seems to depend on how homecare nurses manage to locate it and use it in a more or less person-centred manner. Communication skills and attentiveness to psychosocial aspects of patient care stand out as important attributes for nursing in this context.

Program assessment framework for a rural palliative supportive service

Although there are a number of quality frameworks available for evaluating palliative services, it is necessary to adapt these frameworks to models of care designed for the rural context. The purpose of this paper was to describe the development of a program assessment framework for evaluating a rural palliative supportive service as part of a community-based research project designed to enhance the quality of care for patients and families living with life-limiting chronic illness. A review of key documents from electronic databases and grey literature resulted in the identification of general principles for high-quality palliative care in rural contexts. These principles were then adapted to provide an assessment framework for the evaluation of the rural palliative supportive service. This framework was evaluated and refined using a community-based advisory committee guiding the development of the service. The resulting program assessment framework includes 48 criteria organized under seven themes: embedded within community; palliative care is timely, comprehensive, and continuous; access to palliative care education and experts; effective teamwork and communication; family partnerships; policies and services that support rural capacity and values; and systematic approach for measuring and improving outcomes of care. It is important to identify essential elements for assessing the quality of services designed to improve rural palliative care, taking into account the strengths of rural communities and addressing common challenges. The program assessment framework has potential to increase the likelihood of desired outcomes in palliative care provisions in rural settings and requires further validation.

Among neighbors: an ethnographic account of responsibilities in rural palliative care

OBJECTIVE

Building high quality palliative care in rural areas must take into account the cultural dimensions of the rural context. The purpose of this qualitative study was to conduct an exploration of rural palliative care, with a particular focus on the responsibilities that support good palliative care from rural participants' perspectives.

METHOD

This ethnographic study was conducted in four rural communities in Western Canada between June 2009 and September 2010. Data included 51 days of field work, 95 semistructured interviews, and 74 hours of direct participant observation. Thematic analysis was used to provide a descriptive account of rural palliative care responsibilities.

RESULTS

Findings focus on the complex web of responsibilities involving family, healthcare professionals, and administrators. Family practices of responsibility included provision of direct care, managing and coordinating care, and advocacy. Healthcare professional practices of responsibility consisted of interpreting their own competency in relation to palliative care, negotiating their role in relation to that interpretation, and individualizing care through a bureaucratic system. Administrators had three primary responsibilities in relation to palliative care delivery in their community: navigating the politics of palliative care, understanding the culture of the community, and communicating with the community.

SIGNIFICANCE OF RESULTS

Findings provide important insights into the complex ways rurality influences understandings of responsibility in palliative care. Families, healthcare providers, and administrators work together in fluid ways to support high quality palliative care in their communities. However, the very fluidity of these responsibilities can also work against high quality care, and are easily disrupted by healthcare changes. Proposed healthcare policy and practice changes, particularly those that originate from outside of the community, should undergo a careful analysis of their potential impact on the longstanding negotiated responsibilities.

Understanding the landscape: promoting health for rural individuals after tertiary level cardiac revascularization

PURPOSE

The purpose of this pilot study was to describe the needs and experiences of rural individuals commuting to an urban center for percutaneous coronary intervention (PCI).

METHODS

Data were analyzed from a "Patient Adherence and Satisfaction Survey" conducted by telephone as part of a quality improvement focus, and supplemented with in-depth semi-structured interviews with rural patients following PCI.

FINDINGS

Both urban and rural patients after PCI experienced few complications, had made some attempts to reduce tobacco usage, and were highly satisfied with explanations of their treatment and their overall treatment experience. Patients in rural settings were more likely to experience chest pain at least rarely following their surgery than people in urban settings (P < .05). Data on participation in cardiac rehabilitation (CR) showed no significant differences between urban and rural dwellers. Four themes emerged from the interviews: standards of care during treatment; transportation; local resources and community support; and lifestyle changes. Although patients were highly satisfied with standards of care during acute treatment, there were unmet needs in relation to transportation and lifestyle changes.

CONCLUSION

Transitions between rural communities and urban centers and rural adaptations of secondary prevention programs require more attention in health service delivery. Further research is required to better understand potential variations in chest pain patterns between urban and rural residents.

Rural nursing and quality end-of-life care: palliative care ... palliative approach ... or somewhere in-between?

Secondary analysis of data from 2 studies examining palliative care in rural areas was conducted with the aim to better understand how a nursing palliative approach influences quality outcomes at end-of-life. Nurses' ways of being that brought connection and comfort at end-of-life included paying attention to time, privacy, and family support. The rural context with its geography, relationships, and unique resources influenced nurses' abilities to enact a palliative approach. Findings demonstrate that urban-centric models of palliative care do not fit well in rural nursing practice and highlight the importance of understanding the rural context.