Organization and evaluation of generalist palliative care in a Danish hospital

'Without Them, There Would Be Almost Nothing' - Experiences of Interacting With Volunteers in Everyday Life in Nursing Homes - Perspectives of Residents and Next of Kin

The study's aim is to explore the experiences of nursing home residents and their next of kin related to interacting with volunteers in daily life and when the resident's death is imminent. Qualitative data consisted of 130 hours of participant observations in three nursing homes and 13 interviews with five residents and eight next of kin. A thematic analysis identified three themes: (1) Social everyday activities - a frame for responsiveness and meaningful everydayness - reflecting the existential dimension of these activities; (2) Time - contrasting volunteers' time for care activities and bedside support to dying residents with professionals' time for similar activities; and (3) Valuable relief when death is imminent - inherent ethical dilemmas - reflecting potential tension between the valuable relief volunteers provide and the preferences of residents and their next of kin. Volunteers can promote and improve a holistic palliative care approach for residents in nursing homes.

Identification of core indicators for the integration of a palliative care approach in hospitals: An international Delphi study

BACKGROUND

Healthcare providers working in hospitals have significant exposure to patients with palliative care needs. For many patients, these needs often reflect non-specialist rather than specialist palliative care needs. Embedding a palliative care approach in acute hospital-based care however is challenging.

AIM

To identify core indicators for the integration of a palliative care approach in hospitals.

DESIGN

A Delphi technique used three sequential online survey rounds. Preliminary indicators were identified in a concept analysis of a palliative care approach, and a systematic review of hospital-based healthcare providers' views of a palliative care approach.

PARTICIPANTS

An international expert panel of three key stakeholder groups (clinicians, researchers, patients/family members) participated in each Delphi round.

RESULTS

The Delphi participants were recruited from 12 countries; 97 individuals responded to round 1, 78 to round 2 and 72 to round 3 (74% overall response rate). Consensus was achieved (defined a priori as >70%) on 32 core indicators of a hospital-based palliative care approach, with five structural indicators (relating to infrastructure and governance), 21 organisational indicators (relating to clinical care processes) and six staff indicators (relating to training and support for healthcare providers).

CONCLUSIONS

This study offers multi-level guidance for clinical practice, policy and research related to integration of a palliative care approach in hospitals, based on evidence and international consensus from major stakeholder groups. These core indicators provide a means to assess, review and communicate the core elements of a palliative care approach in hospitals.

When and how to stop palliative antineoplastic treatment and to organise palliative care for patients with incurable cancer

BACKGROUND

Improving the organisational aspects of the delivery of palliative care in order to support patients throughout their disease trajectory has received limited attention.

AIM

To investigate the opportunities and barriers related to organising palliation for people with terminal cancer and their families.

METHODS

An explorative interview study was conducted among 31 nurses and three physicians concerning an intervention facilitating a fast transition from treatment at a cancer centre at a university hospital to palliation at home. A thematic analysis was conducted.

FINDINGS

This article presents three out of seven themes: 1) improvement in the cessation of antineoplastic treatment in palliation; 2) improvement in organisations delivering palliation; and 3) improvement in multidisciplinary and cross-sectoral collaboration.

CONCLUSIONS

The results demonstrate the demand for flexible, family-centred and integrated palliation at all levels, from communication and the collaborative relationship between healthcare professionals and families to service sectors.

Health inequalities for older people from minority ethnic groups receiving palliative care and end of life care: A scoping review protocol

OBJECTIVE

The proposed scoping review aims to explore international literature on how older people from minority ethnic groups engage with and utilise palliative and end of life care, investigate the barriers and facilitators, and compare how this varies between ethnicities and health conditions.

INTRODUCTION

Minority ethnic groups make up substantial parts of the populations of many countries around the world. Research has found that there are disparities in access to palliative care and end of life care among minority ethnic groups. Language barriers, cultural values, and socio-demographic factors have been cited as preventing access to quality palliative and end of life care. However, it is unclear how these barriers and inequalities differ across different minority ethnic groups in different countries, and across different health conditions within these groups.

INCLUSION CRITERIA

The population will be older people of different minority ethnic groups who are receiving palliative or end of life care, family caregivers, and health and social care professionals. The sources of information will include quantitative, qualitative and mixed methods research, and sources that focus on minority ethnic groups' interactions with palliative and end of life care.

METHODS

A scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis. Searches of MEDLINE, Embase, PsycInfo, CINAHL, Scopus, Web of Science, Assia, and the Cochrane Library will be conducted. Citation tracking, reference list checking and grey literature searches will be undertaken. Data will be extracted, charted and summarised descriptively.

IMPLICATIONS

This review will highlight the health inequalities present in palliative and end of life care, the research gaps in understudied minority ethnic populations, locations where further study is required, and how barriers and facilitators differ across different ethnic groups and health conditions. The results of this review will be shared with stakeholders and will provide evidence-based recommendations for inclusive palliative and end of life care.

Presuppositions, cost–benefit, collaboration, and competency impacts palliative care referral in paediatric oncology: a qualitative study

Background

Although a significant proportion of children with cancer need palliative care, few are referred or referred late, with oncologists and haematologists gatekeeping the referral process. We aimed to explore the facilitators and barriers to palliative care referral.

Methods

Twenty-two paediatric oncologists and haematologists were purposively recruited and interviewed. Data were analysed using reflexive thematic analysis. Findings were interpreted using the critical realist paradigm.

Results

Four themes were generated. 1) Oncologists expressed concern about the competency of palliative care teams. Palliative care often symbolised therapeutic failure and abandonment, which hindered referral. Trustworthy palliative care providers had clinical competence, benevolence, and knowledge of oncology and paediatrics. 2) Making a palliative care referral was associated with stigma, navigating illness-related factors, negative family attitudes and limited resources, impeding palliative care referral. 3) There were benefits to palliative care referral, including symptom management and psychosocial support for patients. However, some could see interactions with the palliative care team as interference hindering future referrals. 4) Suggested strategies for developing an integrated palliative care model include evident collaboration between oncology and palliative care, early referral, rebranding palliative care as symptom control and an accessible, knowledgeable, and proactive palliative care team.

Conclusion

Presuppositions about palliative care, the task of making a referral, and its cost-benefits influenced referral behaviour. Early association with an efficient rebranded palliative care team might enhance integration.

Volunteers do the fun stuff -- Experiences from volunteer-professional caregiver cooperation in nursing homes

BACKGROUND

The number of volunteers in Danish nursing homes is increasing. Volunteers cooperate with professional caregivers to improve the residents' well-being and quality of life as part of their palliative care. The Danish government encourages this volunteer involvement, which is partly intended to alleviate the resource constraints in municipal healthcare. Although volunteer roles are defined as complementary to the professional caregiver role, volunteer-professional caregiver cooperation can be challenging.

AIM

This article explores the challenges experienced in volunteer-professional caregiver cooperation in the general palliative care provided in nursing homes.

METHOD

A qualitative design and a sociological phenomenological approach were adopted to answer the research question: What is experienced as challenging in the cooperation between volunteer and professional caregivers in the provision of care for elderly residents in everyday life in a nursing home? And what meanings and understandings are associated with these experiences? Data were collected by combining participant observations and interviews, and thematic analysis structured the analytical process.

FINDINGS

The analysis of 115 hours of participant observations in two Danish nursing homes with 50-60 volunteers involved and 16 interviews (eight with volunteers, eight with professional caregivers) identified two overall themes: 'Symbolic indications of them and us' (two sub-themes) and 'Meaning and action regarding the residents best interest' (three sub-themes).

CONCLUSIONS

An institutional distinction between volunteer versus professional caregiver domains contributed to a sense of 'them and us', which hindered common experiences and raised challenges concerning the mutual understanding of actions. The professional caregivers felt that they lacked the time to engage in social care activities with residents, for which volunteers otherwise had time. The coordinator role was a crucial link in coordinating the daily care activities for residents but marked by a sense of ambivalence among the professional caregivers.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Barriers to specialist palliative care in interstitial lung disease: a systematic review

Background

Current guidelines recommend palliative care based on individual needs for patients with idiopathic pulmonary fibrosis. However, patients with interstitial lung disease (ILD) are less likely to receive specialist palliative care services compared with patients with malignant disease. The aim of this review is to summarise recent studies addressing barriers to referring patients to specialist palliative care services.

Methods

PubMed, Embase, Medline and Web of Science were reviewed to identify relevant publications. Studies were selected if they examined the frequency of specialist palliative care referral and/or addressed issues surrounding access to palliative care services for patients with ILD.

Results

Ten studies with a total of 4073 people with ILD, 27 caregivers and 18 healthcare professionals were selected and analysed. Frequency of palliative care referrals ranged from 0% to 38%. Delay in palliative care referrals and end-of-life decisions, patients’ fear of talking about the future, prognostic uncertainty and confusion about the roles of palliative care were identified as barriers to accessing palliative care services.

Conclusion

Further research should concentrate on the early identification of patients who need specialist palliative care possibly with establishment of criteria to trigger referral ensuring that referrals are also based on patient’s needs.

First year experiences with a palliative out-patients structure for patients with COPD: a qualitative study of health professionals' expectations and experiences

Background

To improve the care of patients with advanced COPD and be able to address their palliative needs a new outpatient organization (CAPTAIN) was developed and implemented. CAPTAIN was inspired by best practice and existing guidelines and changed the traditional organization of an outpatient structure including the roles of nurses and doctors. Only sparse knowledge exists of the health professionals’ expectations and experiences to organizational changes in an outpatient setting. This insight is necessary as health professionals are key stakeholders in implementing new structures and successfully transforming knowledge into practice. The aim of this study was to explore the health professionals’ expectations and experiences of a new palliative out-patients structure for patients with advanced COPD.

Methods

The design was interpretive description as described by Thorne. Focus groups and individual interviews were conducted with pulmonary nurses, pulmonary doctors and municipality nurses from 2014 to 2016.

Results

The overall theme was dualism. Both nurses and doctors were pending between aspiration and concern in their expectations to the new structure, meanwhile their actual experiences were pending between perceived gain and improvements versus consequences with the new structure. Nurses’ and doctors’ existing practice was altered and the new structure required new ways for them to cooperate and ways in which skills from each profession were most efficiently utilized.

Conclusion

Nurses and doctors considered the new structure as a quality boost and it fulfilled their hope of improving the quality of care offered to patients with advanced COPD, however with increased work-related stress as a derived consequence.

Generalist palliative care in hospital - Cultural and organisational interactions. Results of a mixed-methods study

BACKGROUND

It can be challenging to provide generalist palliative care in hospitals, owing to difficulties in integrating disease-oriented treatment with palliative care and the influences of cultural and organisational conditions. However, knowledge on the interactions that occur is sparse.

AIM

To investigate the interactions between organisation and culture as conditions for integrated palliative care in hospital and, if possible, to suggest workable solutions for the provision of generalist palliative care.

DESIGN

A convergent parallel mixed-methods design was chosen using two independent studies: a quantitative study, in which three independent datasets were triangulated to study the organisation and evaluation of generalist palliative care, and a qualitative, ethnographic study exploring the culture of generalist palliative nursing care in medical departments.

SETTING/PARTICIPANTS

A Danish regional hospital with 29 department managements and one hospital management.

RESULTS

Two overall themes emerged: (1) 'generalist palliative care as a priority at the hospital', suggesting contrasting issues regarding prioritisation of palliative care at different organisational levels, and (2) 'knowledge and use of generalist palliative care clinical guideline', suggesting that the guideline had not reached all levels of the organisation.

CONCLUSION

Contrasting issues in the hospital's provision of generalist palliative care at different organisational levels seem to hamper the interactions between organisation and culture - interactions that appear to be necessary for the provision of integrated palliative care in the hospital. The implementation of palliative care is also hindered by the main focus being on disease-oriented treatment, which is reflected at all the organisational levels.