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Santos Salas A, LeGuerrier B, Horvath L, Bassah N, Adewale B, Bardales O, Duggleby W, Salami B, Watanabe SM. The impact of socioeconomic inequality on access to health care for patients with advanced cancer: A qualitative study. Asia Pac J Oncol Nurs 2024; 11:100520. [PMID: 39027088 PMCID: PMC11255108 DOI: 10.1016/j.apjon.2024.100520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/17/2024] [Indexed: 07/20/2024] Open
Abstract
Objective In Canada, populations experiencing socioeconomic inequality have lower rates of access to screening and diagnosis and higher mortality rates than people from higher-income areas. Limited evidence exists concerning their experiences when living with advanced cancer. We explored how socioeconomic inequality shapes the experiences of patients with advanced cancer. Methods We utilized a qualitative study design that combined tenets of hermeneutic phenomenological inquiry and critical theory. Four individuals with advanced cancer from low-income neighborhoods, three family members, and six cancer care providers were accrued through a tertiary cancer center in a western Canadian city. One-on-one interviews and brief notes were used for data collection. Data were analyzed through thematic analysis. Results Three interrelated themes were identified: 'Lack of access to socioeconomic supports,' 'Gaps in access to health care resources and services,' and 'Limited access to symptom relief.' Patients experienced inadequate finances, housing, and transportation. Most patients lived alone and had limited family and social support. Patients reported lack of knowledge of available resources and health system navigation issues, including communication problems with providers and among levels of care. Cancer care providers and patients described issues achieving symptom relief as well as challenges associated with extensive disease. Conclusions Study findings suggest that socioeconomic inequality interferes with the ability of persons with advanced cancer to access health care and contributes to less optimal cancer outcomes. Socioeconomic inequality may increase symptom severity. Findings call for the development of tailored interventions for populations with advanced cancer and socioeconomic inequality.
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Affiliation(s)
- Anna Santos Salas
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Bronwen LeGuerrier
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Lucas Horvath
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Nahyeni Bassah
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Bisi Adewale
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Olga Bardales
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Wendy Duggleby
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Bukola Salami
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sharon M. Watanabe
- Department of Symptom Control and Palliative Care, Cross Cancer Institute, Division of Palliative Care Medicine, Department of Oncology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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Allard E, Dumaine S, Sasseville M, Gabet M, Duhoux A. Quality of palliative and end-of-life care: a qualitative study of experts' recommendations to improve indicators in Quebec (Canada). BMC Palliat Care 2024; 23:146. [PMID: 38858720 PMCID: PMC11163802 DOI: 10.1186/s12904-024-01474-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/28/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND In 2021, the National Institute of Public Health (INSPQ) (Quebec, Canada), published an update of the palliative and end-of-life care (PEoLC) indicators. Using these updated indicators, this qualitative study aimed to explore the point of view of PEoLC experts on how to improve access and quality of care as well as policies surrounding end-of-life care. METHODS Semi-directed interviews were conducted with palliative care and policy experts, who were asked to share their interpretations on the updated indicators and their recommendations to improve PEoLC. A thematic analysis method was used. RESULTS The results highlight two categories of interpretations and recommendations pertaining to: (1) data and indicators and (2) clinical and organizational practice. Participants highlight the lack of reliability and quality of the data and indicators used by political and clinical stakeholders in evaluating PEoLC. To improve data and indicators, they recommend: improving the rigour and quality of collected data, assessing death percentages in all healthcare settings, promoting research on quality of care, comparing data to EOL care directives, assessing use of services in EOL, and creating an observatory on PEoLC. Participants also identified barriers and disparities in accessing PEoLC as well as inconsistency in quality of care. To improve PEoLC, they recommend: early identification of palliative care patients, improving training for all healthcare professionals, optimizing professional practice, integrating interdisciplinary teams, and developing awareness on access disparities. CONCLUSIONS Results show that PEoLC is an important aspect of public health. Recommendations issued are relevant to improve PEoLC in and outside Quebec.
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Affiliation(s)
- Emilie Allard
- Faculty of Nursing, University of Montreal, PO Box 6128, Centre-ville Station, Montréal, QC, H3C 3J7, Canada.
| | - Sarah Dumaine
- Faculty of Nursing, University of Montreal, PO Box 6128, Centre-ville Station, Montréal, QC, H3C 3J7, Canada
| | - Martin Sasseville
- Centre de recherche Charles-Le Moyne (CRCLM), Campus de Longueuil - Université de Sherbrooke, 150 Place Charles LeMoyne - Bureau 200, Longueuil, QC, J4K 0A8, Canada
| | - Morgane Gabet
- School of Public Health, University of Montreal, 7101 Av du Parc, Montréal, QC, H3N 1X9, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, University of Montreal, PO Box 6128, Centre-ville Station, Montréal, QC, H3C 3J7, Canada
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Bourgeois A, Horrill T, Mollison A, Stringer E, Lambert LK, Stajduhar K. Barriers to cancer treatment for people experiencing socioeconomic disadvantage in high-income countries: a scoping review. BMC Health Serv Res 2024; 24:670. [PMID: 38807237 PMCID: PMC11134650 DOI: 10.1186/s12913-024-11129-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Despite advances in cancer research and treatment, the burden of cancer is not evenly distributed. People experiencing socioeconomic disadvantage have higher rates of cancer, later stage at diagnoses, and are dying of cancers that are preventable and screen-detectable. However, less is known about barriers to accessing cancer treatment. METHODS We conducted a scoping review of studies examining barriers to accessing cancer treatment for populations experiencing socioeconomic disadvantage in high-income countries, searched across four biomedical databases. Studies published in English between 2008 and 2021 in high-income countries, as defined by the World Bank, and reporting on barriers to cancer treatment were included. RESULTS A total of 20 studies were identified. Most (n = 16) reported data from the United States, and the remaining included publications were from Canada (n = 1), Ireland (n = 1), United Kingdom (n = 1), and a scoping review (n = 1). The majority of studies (n = 9) focused on barriers to breast cancer treatment. The most common barriers included: inadequate insurance and financial constraints (n = 16); unstable housing (n = 5); geographical distribution of services and transportation challenges (n = 4); limited resources for social care needs (n = 7); communication challenges (n = 9); system disintegration (n = 5); implicit bias (n = 4); advanced diagnosis and comorbidities (n = 8); psychosocial dimensions and contexts (n = 6); and limited social support networks (n = 3). The compounding effect of multiple barriers exacerbated poor access to cancer treatment, with relevance across many social locations. CONCLUSION This review highlights barriers to cancer treatment across multiple levels, and underscores the importance of identifying patients at risk for socioeconomic disadvantage to improve access to treatment and cancer outcomes. Findings provide an understanding of barriers that can inform future, equity-oriented policy, practice, and service innovation.
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Affiliation(s)
- Amber Bourgeois
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada.
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada.
| | - Tara Horrill
- College of Nursing, University of Manitoba, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada
| | - Ashley Mollison
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada
| | - Eleah Stringer
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
| | - Leah K Lambert
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
- School of Nursing, University of British Columbia, 2211 Wesbrook Mall T201, Vancouver, BC, V6T 2B5, Canada
| | - Kelli Stajduhar
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada
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Lau J, Scott MM, Everett K, Gomes T, Tanuseputro P, Jennings S, Bagnarol R, Zimmermann C, Isenberg SR. Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada. CMAJ 2024; 196:E547-E557. [PMID: 38684285 PMCID: PMC11057880 DOI: 10.1503/cmaj.231419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD. METHODS We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury). RESULTS Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death. INTERPRETATION Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.
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Affiliation(s)
- Jenny Lau
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
| | - Mary M Scott
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Karl Everett
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sheila Jennings
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Rebecca Bagnarol
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Camilla Zimmermann
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Division of Palliative Care (Lau, Bagnarol, Zimmermann), Princess Margaret Cancer Centre, University Health Network; Division of Palliative Care (Lau), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Scott, Tanuseputro), Ottawa, Ont.; ICES Central (Everett, Gomes); Li Ka Shing Knowledge Institute (Gomes), Unity Health; Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto, Toronto, Ont.; Bruyère Research Institute (Tanuseputro, Isenberg), Ottawa, Ont.; Moms Stop The Harm (Jennings); Division of Palliative Medicine (Zimmermann), Department of Medicine, University of Toronto, Toronto, Ont.; Division of Palliative Care (Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
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Tegegne BA, Alehegn AA, Kassahun M. Drug Use Evaluation of Tenofovir/Lamivudine/Dolutegravir (TLD) Fixed-Dose Combination for Initiation and Transition Among HIV-Infected Individuals Attending Lumame Primary Hospital, North West Ethiopia. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2024; 13:31-42. [PMID: 38650710 PMCID: PMC11034558 DOI: 10.2147/iprp.s455351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024] Open
Abstract
Background A key strategy for quality improvement is drug use evaluation, which looks at the safe, appropriate use of medication principles. Tenofovir/Lamivudine/Dolutegravir (TLD-FDC) usage has not yet been sufficiently examined in published literature. The purpose of this study was to assess how TLD were used by HIV-positive patients Using WHO drug use evaluation standards in Lumame Primary Hospital, North West Ethiopia. Methods Using WHO drug use evaluation standards, a retrospective study design was used to evaluate the appropriateness of TLD use. Systematic random sampling was utilized to gather patient medical records containing TLD. Accordingly, 100 records that met the inclusion criteria were selected and reviewed between April 1 and 15, 2021. Five criteria, namely, indication, dose, contraindication, drug interaction, and TLD safety monitoring were used to evaluate the appropriateness of TLD utilization. Results 80% of patients were transited to TLD from other regimens. The median time on TLD was found to be 13 months with 9 months to 18 months IQR. The latest CD4 count as well as CD4 count at the initiation or transition of TLD was not done for 75% and 89% of the patients, respectively. 3/4 (75%) of the patients were found to have a scheduled medication refill history. TLD dosing, indications, and contraindications were found to be 100% appropriate. No, TLD safety monitoring tests were done for 21% of the patients in this study. However, viral load, liver/kidney function, and serum creatinine tests were done for 77% (95% CI: 74%-79%), 5% (95% CI: 2%-8%), and 14% (95% CI: 11%-17%) of the patients, respectively. More over, In 93% (95% CI: 91%-95%) of the patients, the TLD interaction was appropriate; in 7%, it was not. All recording, documenting, and reporting technologies were available and used efficiently, except for the Electronic Dispensing Tool. Conclusion Generally, good adherence to national and WHO guidelines was obtained regarding dose, indication, and contraindications. However, improvement in safety monitoring tests and CPT utilization is recommended. Drug interactions satisfied the majority of the criteria's threshold, while certain standards were not followed.
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Affiliation(s)
- Bantayehu Addis Tegegne
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Agumas Alemu Alehegn
- Department of Pharmacy, Lumame Primary Hospital, Lumame, Ethiopia; Health Supplies and Laboratory Equipments Management Directorate Director, Amhara National Regional State Public Health Institute, Bahirdar, Ethiopia
| | - Mengistie Kassahun
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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Quinn S, Ferguson L, Read D, Richards N. "The great escape": how an incident of elopement gave rise to trauma informed palliative care for a patient experiencing multiple disadvantage. BMC Palliat Care 2024; 23:61. [PMID: 38419002 PMCID: PMC10900545 DOI: 10.1186/s12904-024-01374-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND This case report from Scotland, UK illustrates how unresolved traumatic experiences across the life course can affect a patient's engagement with palliative care and offers insights into the flexibility and adaptations necessary for taking a trauma informed approach to care for an individual experiencing multiple disadvantage. Trauma informed care is a cornerstone in the pursuit of equitable palliative care, particularly for those facing multiple disadvantage, as it acknowledges the impact of past traumas on current healthcare experiences, and fosters an environment of understanding, acceptance, and tailored support to alleviate suffering in the final stages of life. CASE PRESENTATION "M" was a veteran with a history of homelessness, living with end stage anal cancer and symptoms consistent with post-traumatic stress disorder, although he never received a formal diagnosis. M exhibited complex behaviours perceived to be related to his history of trauma, including his decision to elope from the hospice, reluctance to accept personal care from nurses, and unpredictability. These behaviours posed a significant challenge to his palliative care team, both in the hospice and at home. An individualised and flexible approach to care delivery was eventually adopted, which included a 'safety-netting' approach and care delivery outside of the hospice. M was ultimately supported to remain at home until a week before he died. CONCLUSION M's case underscores the necessity of adopting a trauma informed approach to palliative care, particularly for patients with a history of trauma and multiple disadvantage. The case highlights the importance of understanding and respecting a patient's past traumas, promoting safety and autonomy, and ensuring flexibility in care delivery.
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Affiliation(s)
- Sam Quinn
- End of Life Studies Group, University of Glasgow, Dumfries Campus, Dumfries and Galloway, Scotland, DG1 4ZL, UK.
| | - Libby Ferguson
- Marie Curie Scotland, 133 Balornock Road, Stobhill, Glasgow, Scotland, G21 3US, UK
| | | | - Naomi Richards
- End of Life Studies Group, University of Glasgow, Dumfries Campus, Dumfries and Galloway, Scotland, DG1 4ZL, UK
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Stajduhar KI, Giesbrecht M, Mollison A, Whitlock K, Burek P, Black F, Gerke J, Dosani N, Colgan S. "You can't die here": an exploration of the barriers to dying-in-place for structurally vulnerable populations in an urban centre in British Columbia, Canada. BMC Palliat Care 2024; 23:12. [PMID: 38200482 PMCID: PMC10782732 DOI: 10.1186/s12904-024-01340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/03/2024] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND One measure of quality in palliative care involves ensuring people approaching the end of life are able to receive care, and ultimately die, in the places they choose. Canadian palliative care policy directives stem from this tenet of autonomy, acknowledging that most people prefer to die at home, where they feel safe and comfortable. Limited research, however, considers the lack of 'choice' people positioned as structurally vulnerable (e.g., experiencing extreme poverty, homelessness, substance-use/criminalization, etc.) have in regard to places of care and death, with the option of dying-in-place most often denied. METHODS Drawing from ethnographic and participatory action research data collected during two studies that took place from 2014 to 2019 in an urban centre in British Columbia, Canada, this analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place. Participants include: (1) people positioned as structurally vulnerable on a palliative trajectory; (2) their informal support persons/family caregivers (e.g., street family); (3) community service providers (e.g., housing workers, medical professionals); and (4) key informants (e.g., managers, medical directors, executive directors). Data includes observational fieldnotes, focus group and interviews transcripts. Interpretive thematic analytic techniques were employed. RESULTS Participants on a palliative trajectory lacked access to stable, affordable, or permanent housing, yet expressed their desire to stay 'in-place' at the end of life. Analysis reveals three main barriers impeding their 'choice' to remain in-place at the end of life: (1) Misaligned perceptions of risk and safety; (2) Challenges managing pain in the context of substance use, stigma, and discrimination; and (3) Gaps between protocols, policies, and procedures for health teams. CONCLUSIONS Findings demonstrate how the rhetoric of 'choice' in regard to preferred place of death is ethically problematic because experienced inequities are produced and constrained by socio-structural forces that reach beyond individuals' control. Ultimately, our findings contribute suggestions for policy, programs and practice to enhance inclusiveness in palliative care. Re-defining 'home' within palliative care, enhancing supports, education, and training for community care workers, integrating palliative approaches to care into the everyday work of non-health care providers, and acknowledging, valuing, and building upon existing relations of care can help to overcome existing barriers to delivering palliative care in various settings and increase the opportunity for all to spend their end of life in the places that they prefer.
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Affiliation(s)
- Kelli I Stajduhar
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Melissa Giesbrecht
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada.
| | - Ashley Mollison
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Kara Whitlock
- Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Piotr Burek
- Canadian Institute for Substance Use Research, University of Victoria, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Fraser Black
- Faculty of Medicine - Island Medical Program, University of British Columbia, 3800 Finnerty Road, Victoria, BC, V8P 5C2, Canada
| | - Jill Gerke
- Palliative and End of Life Care Program, Vancouver Island Health Authority, 1952 Bay Street, Victoria, BC, V8R 1J8, Canada
| | - Naheed Dosani
- Palliative Care Physician, Department of Family & Community Medicine, St Michael's Hospital at Unity Health Toronto, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Simon Colgan
- Cumming School of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, AB, T2N 1N4, Canada
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8
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Hudson BF, Dzeng E, Burnett A, Yeung M, Shulman C. Palliative care, homelessness, and restricted or uncertain immigration status. Palliat Care Soc Pract 2023; 17:26323524231216993. [PMID: 38144973 PMCID: PMC10748891 DOI: 10.1177/26323524231216993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/07/2023] [Indexed: 12/26/2023] Open
Abstract
Background People experiencing homelessness have limited access to palliative care support despite high levels of ill health and premature mortality. Most research exploring these challenges in the United Kingdom has focused on people living in hostels or temporary accommodation. People with uncertain or restricted immigration status are often unable to access this accommodation due to lack of entitlement to benefits. There is little research about the experiences of those in the United Kingdom who cannot access hostels or temporary accommodation due to restricted or uncertain immigration status with regards to palliative and end-of-life care access. Aim To explore the barriers to palliative and end-of-life care access for people with uncertain or restricted immigration status, who are experiencing homelessness and have advanced ill health, and the experiences of UK hospices of supporting people in this situation. Design A multi-method cross-sectional study. Setting/participants An online survey for hospice staff followed by online focus groups with staff from inclusion health, homelessness and palliative care services, charities and interviews with people experiencing homelessness. Results Fifty hospice staff responded to the online survey and 17 people participated in focus groups and interviews (focus groups: n = 10; interviews: n = 7). The survey demonstrated how hospices are not currently supporting many people with restricted or uncertain immigration status who are homeless and that hospice staff have received limited training around eligibility for entitlements or National Health Service (NHS) care. Interview and focus group data demonstrated high levels of unmet need. Reasons for this included a lack of consistency around eligibility for support from local authorities, issues relating to NHS charging, and mistrust and limited knowledge of the UK health and social care system. These barriers leave many people unable to access care toward the end of their lives. Conclusion To advocate for and provide compassionate palliative and end-of-life care for people with uncertain immigration status, there is need for more legal literacy, with training around people's entitlement to care and support, as well as easier access to specialist legal advice.
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Affiliation(s)
- Briony F. Hudson
- Marie Curie, One Embassy Gardens, 8 Viaduct Gardens, London SW11 7BW, UK
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK Pathway, London, UK
| | - Elizabeth Dzeng
- Department of Global Health and Social Medicine, King’s College London, London, UK
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Michelle Yeung
- Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Caroline Shulman
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, UK
- Pathway, London, UK
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9
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Butler H, Gott M, Prebble DK, Fortune DS, Robinson DJ. Palliative care research utilising intersectionality: a scoping review. BMC Palliat Care 2023; 22:189. [PMID: 38012662 PMCID: PMC10683236 DOI: 10.1186/s12904-023-01310-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Access to palliative care is recognised as a human right, yet clear disparities exist. There have been recent appeals to examine people's contexts and interactions with social systems which for many, adversely influence their utilisation of palliative care. Intersectionality provides a way to understand these drivers of inequity and ultimately advocate for change. AIM To identify and describe published studies utilising intersectionality in relation to need, access and experience of palliative care. DESIGN A scoping review. DATA SOURCES Medline, PsycINFO, CINAHL and Google Scholar databases and a manual search were undertaken for studies published up to January 2023. Included studies were evidence based articles where palliative or end of life care was the focus and intersectionality was identified and/or applied to the research that was undertaken. RESULTS Ten published studies were included. An analytic framework was developed to identify the extent that intersectionality was utilised in each study. A wide range of different groups were researched across the studies, with most focusing on aspects of their participant's identity in relation to palliative care access and experience. Common topics of power, heterogeneity of people within the health system and barriers to palliative care were illuminated across the studies. CONCLUSIONS Very limited research to date has utilised intersectionality to understand access, utilisation and experience of palliative care. This scoping review demonstrates intersectionality can provide a way to illuminate rich understandings of inequity in palliative care. It is imperative that future palliative research incorporates an intersectionality focus to further clarify the needs and experiences of structurally marginalised groups.
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Affiliation(s)
- Helen Butler
- School of Nursing, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Merryn Gott
- School of Nursing, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Doctor Kate Prebble
- School of Nursing, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Doctor Sarah Fortune
- School of Population Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Doctor Jackie Robinson
- School of Nursing, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
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10
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Werner K, Alsuhaibani SA, Alsukait RF, Alshehri R, Herbst CH, Alhajji M, Lin TK. Behavioural economic interventions to reduce health care appointment non-attendance: a systematic review and meta-analysis. BMC Health Serv Res 2023; 23:1136. [PMID: 37872612 PMCID: PMC10594857 DOI: 10.1186/s12913-023-10059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/24/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Appointment non-attendance - often referred to as "missed appointments", "patient no-show", or "did not attend (DNA)" - causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts - where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments. METHODS We systematically searched four databases (PubMed/Medline, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design. RESULTS Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed. CONCLUSION The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test alternative behavioural economic interventions that have not been used, tested, and/or published before.
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Affiliation(s)
- Kalin Werner
- Institute for Health & Aging, Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Sara Abdulrahman Alsuhaibani
- Nudge Unit, Ministry of Health, Riyadh, KSA, Saudi Arabia
- Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh, KSA, Saudi Arabia
| | - Reem F Alsukait
- Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, KSA, Saudi Arabia
- Health, Nutrition and Population Global Practice, The World Bank, Washington, D.C, USA
| | - Reem Alshehri
- Nudge Unit, Ministry of Health, Riyadh, KSA, Saudi Arabia
| | - Christopher H Herbst
- Health, Nutrition and Population Global Practice, The World Bank, Washington, D.C, USA
| | - Mohammed Alhajji
- Nudge Unit, Ministry of Health, Riyadh, KSA, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, KSA, Saudi Arabia
| | - Tracy Kuo Lin
- Institute for Health & Aging, Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA
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11
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Ashok N, Hughes D, Yardley S. Challenges and opportunities for improvement when people with an intellectual disability or serious mental illness also need palliative care: A qualitative meta-ethnography. Palliat Med 2023; 37:1047-1062. [PMID: 37294100 PMCID: PMC10503257 DOI: 10.1177/02692163231175928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND People with diagnoses of intellectual disability or serious mental illness have higher mortality rates due to physical comorbidities; better understanding is needed to guide best practice in provision of palliative care for these populations. AIMS To identify multivoiced perspectives, drawn from lived experience of: what works, and what does not, in palliative care for people with intellectual disability or serious mental illness; challenges in, and opportunities to improve, palliative care. DESIGN A systematically constructed qualitative meta-ethnography. Protocol published (PROSPERO: CRD42021236616). DATA SOURCES MEDLINE, PsychINFO, CINAHL PLUS and Embase used without date limitations. Papers published in English, containing qualitative data on palliative care provision for people with a diagnosis of intellectual disability or serious mental illness were included. Global five-point strength score applied for relevance/quality appraisal. RESULTS Familiarity (of location, people and/or things) is important for good palliative care. Assumptions and misunderstandings about the role of mental capacity assessment to appropriately involve the patient in decision-making are common. Adapting training for palliative care staff to address concerns and beliefs about mental illness is one of the methods that helps avoid diagnostic overshadowing. Proactive identification of service arrangements to meet needs of persons with personality, psychotic, delusional and bipolar affective disorders will help optimise care. CONCLUSIONS Evidence, including the voices of people with intellectual disability or serious mental illness is urgently needed to guide efforts to improve their access to and experience of palliative care. More evidence is especially needed to understand, develop and implement best practice for people with psychosis, bipolar affective disorder, mania and personality disorder.
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Affiliation(s)
| | | | - Sarah Yardley
- University College London, London, UK
- Central & North West London NHS Foundation Trust, London, UK
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12
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French M, Hansford L, Moeke-Maxwell T. Reflecting on choices and responsibility in palliative care in the context of social disadvantage. Palliat Care Soc Pract 2023; 17:26323524231193037. [PMID: 37654731 PMCID: PMC10467305 DOI: 10.1177/26323524231193037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
There is a need to understand how to improve palliative care provision for people impacted by social inequity. Social inequity, such as that related to socioeconomic circumstances, has profound impacts on experiences of death and dying, posing personal and professional challenges for frontline professionals tasked to ensure that everyone receives the best standard of care at the end of their lives. Recent research has highlighted an urgent need to find ways of supporting healthcare professionals to acknowledge and unpack some of the challenges experienced when trying to deliver equitable palliative care. For example, those involved in patient or person-centred activities within health settings often feel comfortable focusing on individual choice and responsibility. This can become ethically problematic when considering that inequities experienced towards the end of life are produced and constrained by socio-structural forces beyond one individual's control. Ideas and theories originating outside palliative care, including work on structural injustice, cultural safety and capabilities approach, offer an alternative lens through which to consider roles and responsibilities for attending to inequities experienced at the end of life. This paper draws upon these ideas to offer a new way of framing individual responsibility, agency and collective action that may help palliative care professionals to support patients nearing their end of life, and their families, in the context of socioeconomic disadvantage. In this paper, we argue that, ultimately, for action on inequity in palliative care to be effective, it must be coherent with how people understand the production of, and responsibility for, those inequities, something that there is limited understanding of within palliative care.
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Affiliation(s)
- Maddy French
- International Observatory on End of Life Care, Lancaster University, Health Innovation Campus, Sir John Fisher Drive, Lancaster LA1 4YW, UK
| | - Lorraine Hansford
- Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, UK
| | - Tess Moeke-Maxwell
- Te A-rai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
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13
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Janssen DJA, Bajwah S, Boon MH, Coleman C, Currow DC, Devillers A, Vandendungen C, Ekström M, Flewett R, Greenley S, Guldin MB, Jácome C, Johnson MJ, Kurita GP, Maddocks M, Marques A, Pinnock H, Simon ST, Tonia T, Marsaa K. European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease. Eur Respir J 2023; 62:2202014. [PMID: 37290789 DOI: 10.1183/13993003.02014-2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 05/06/2023] [Indexed: 06/10/2023]
Abstract
There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.
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Affiliation(s)
- Daisy J A Janssen
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Health Services Research and Department of Family Medicine, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Michele Hilton Boon
- WiSE Centre for Economic Justice, Glasgow Caledonian University, Glasgow, UK
| | | | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Albert Devillers
- Association Belge Francophone contre la Fibrose Pulmonaire (ABFFP), Rebecq, Belgium
| | - Chantal Vandendungen
- Association Belge Francophone contre la Fibrose Pulmonaire (ABFFP), Rebecq, Belgium
| | - Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund, Sweden
| | | | - Sarah Greenley
- Institute for Clinical and Applied Health Research, Hull York Medical School, University of Hull, Hull, UK
| | | | - Cristina Jácome
- CINTESIS@RISE, Department of Community Medicine, Health Information and Decision, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Geana Paula Kurita
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Multidisciplinary Pain Centre, Department of Anaesthesiology, Pain and Respiratory Support, Neuroscience Centre and Palliative Research Group, Department of Oncology, Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Alda Marques
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA) and Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Hilary Pinnock
- Allergy and Respiratory Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Steffen T Simon
- University of Cologne, Faculty of Medicine and University Hospital, Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), Cologne, Germany
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kristoffer Marsaa
- Department of Multidisease, Nordsjaellands Hospital, University of Copenhagen, Copenhagen, Denmark
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14
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Johnson IM, Light MA. Pathways of Individuals Experiencing Serious Illness While Homeless: An Exploratory 4-Point Typology from the RASCAL-UP Study. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2023; 19:209-228. [PMID: 37331000 DOI: 10.1080/15524256.2023.2223772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
The shifting age demographics of those experiencing homelessness in the United States expose shortcomings and barriers within homelessness response services and safety-net healthcare to address serious illness. The purpose of this study is to describe the common trajectories of patients concurrently experiencing homelessness and serious illness. As a part of the Research, Action, and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study, the study uses patient charts (n = 75) from the only specialty palliative care program in the U.S. specifically for people experiencing homelessness. Through a thematic mixed-method analysis, a four-point typology of care pathways taken by people experiencing homelessness while seriously ill is introduced: (1) aging and dying-in-place within the housing care system; (2) frequent transitions during serious illness; (3) healthcare institutions as housing; and (4) housing as palliation. Implications of this exploratory typology include targeted, site-specific interventions for supporting goal-concordant patient care and assisting researchers and policy makers in appreciating heterogeneity in experience and need among older and chronically ill people experiencing homelessness and housing precarity.
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Affiliation(s)
- Ian M Johnson
- University of Tennessee College of Social Work, Knoxville, Tennessee, USA
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15
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Graven V, Abrahams MB, Pedersen T. Total pain and social suffering: marginalised Greenlanders' end-of-life in Denmark. FRONTIERS IN SOCIOLOGY 2023; 8:1161021. [PMID: 37383482 PMCID: PMC10293635 DOI: 10.3389/fsoc.2023.1161021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/18/2023] [Indexed: 06/30/2023]
Abstract
With a focus on socially marginalised Greenlanders in Denmark, this study explores the significance of the concept of social suffering for the concept of total pain. Greenland is a former Danish colony and Greenlanders retain the right to Danish citizenship with all the benefits of access to the resources of Denmark as any other Danish citizen. However, Greenlanders are overrepresented amongst the most socially disadvantaged in Denmark. They have a disproportionately high risk of early death, often undiagnosed and untreated. This study reports on research conducted with socially marginalised Greenlanders and some of the professionals who work with them. It interrogates the concept of total pain as developed by Cicely Saunders, the founder of modern palliative care. Saunders noted that pain at the end-of-life was not adequately explained by symptoms of a disease process because it was more like a situation that engulfed every aspect of the patient and those close to them; it included physical, psychological, spiritual, and social dimensions. We agree with other scholars that the social dimension of the total pain experience is underexplored. By drawing on the theoretical and methodological lens of intersectionality, our work with marginalised Greenlanders has enabled us to describe the multiple and intersecting social forces that create social suffering for this group. This leads us to conclude that social suffering is not entirely an individual experience but a product of social harm and disadvantage, poverty, inequality, and the various legacies of colonialism, which combine to place some citizens in a harmed condition. Our findings also draw us into a discussion with the concept of total pain and its neglect of the socially constructed nature of social suffering. We conclude by indicating ways in which the concept of total pain can be informed by a more thoroughgoing concept of social suffering. We conclude, with others, that there is a problem of inequity in the way that end-of-life care is currently distributed. Finally, we point to ways in which an understanding of social suffering can help to address the exclusion of some of the most vulnerable citizens from appropriate end-of-life care.
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Affiliation(s)
- Vibeke Graven
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Maja Bangsgaard Abrahams
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tina Pedersen
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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16
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Bourgeois A, Horrill TC, Mollison A, Lambert LK, Stajduhar KI. Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data. Int J Equity Health 2023; 22:58. [PMID: 36998035 PMCID: PMC10064679 DOI: 10.1186/s12939-023-01860-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/13/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context. METHODS We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. RESULTS Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment. CONCLUSION Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.
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Affiliation(s)
- Amber Bourgeois
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada.
| | - Tara C Horrill
- College of Nursing, University of Manitoba, 89 Curry Place Winnipeg, R3T 2N2, Victoria, MB, Canada
| | - Ashley Mollison
- Social Dimensions of Health, University of Victoria Institute on Aging and Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
| | - Leah K Lambert
- School of Nursing, University of British Columbia, BC Cancer Suite 500, 686 West Broadway, V5Z 1G1, Vancouver, BC, Canada
| | - Kelli I Stajduhar
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
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17
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Rollans C, Baek J, Bloch G, Nyhof-Young J, Morey T, Dosani N, Spaner D. Exploring the Barriers and Facilitators Experienced by Palliative Health Care Providers Working with Patients Experiencing Homelessness during the COVID-19 Pandemic. Palliat Med Rep 2023; 4:3-8. [PMID: 36743340 PMCID: PMC9892914 DOI: 10.1089/pmr.2022.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 01/19/2023] Open
Abstract
Background Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications. Objective The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams. Methods Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis. Results Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors. Conclusion Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.
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Affiliation(s)
- Claire Rollans
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Baek
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Address correspondence to: Justine Baek, MD, CFPC, Department of Family and Community Medicine, Mount Sinai Hospital, 60 Murray Street, L4-000 Box #13, Toronto, Ontario M5T 3L9, Canada.
| | - Gary Bloch
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Primary Care, Inner City Health Associates, Toronto, Ontario, Canada
| | - Joyce Nyhof-Young
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Academics Program, Women's College Hospital, Toronto, Ontario, Canada
| | - Trevor Morey
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada
| | - Naheed Dosani
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada
| | - Donna Spaner
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada.,Palliative Care, Toronto Grace Health Centre, Toronto, Ontario, Canada
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18
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Richards N, Quinn S, Mitchell M, Carduff E, Gott M. The viability and appropriateness of using visual methods in end of life research to foreground the experiences of people affected by financial hardship and deprivation. Palliat Med 2023; 37:627-637. [PMID: 36609208 PMCID: PMC10074741 DOI: 10.1177/02692163221146590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Visual methods have been used extensively in social research to explore people's experiences of structural disadvantage. This indicates that they may provide a useful research approach to understanding equity-related concerns within palliative care. However, little has been published regarding the use of visual methods with people at the end of life. PURPOSE OF THE PAPER In this article we draw on our experiences of using visual methods to illuminate the end of life experiences of people experiencing financial hardship and deprivation in Scotland's largest city. EVIDENCE USED TO SUPPORT THE INFORMATION PRESENTED We present evidence from the published literature, as well as our own experiences of using visual methods to explore dying at home for people experiencing financial hardship and deprivation. Our analysis draws on two specific visual methods: photovoice and professional photography. Photovoice is a participatory visual method which involves enabling participants to take and discuss their own images and present them to different audiences to try to enact social change. We report our experiences as researchers, as well as those of our participants and recruitment partners. KEY LEARNING POINTS To successfully use visual methods, researchers need to invest significant time and resource in building a strong rapport with participants. There are also key ethical, practical and representational challenges to consider. A participatory framework should be adopted which ensures agency for participants in terms of image creation and public dissemination. Participants reported value in using visual methods in terms of legacy building and self-representation. Using photovoice (insider's view) and professional photography (outsider's view) together offered complementary perspectives, enabling a rich layering of stories and meaning. Our findings indicate visual methods can illuminate aspects of the end of life experience not captured by other research methods.
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Affiliation(s)
- Naomi Richards
- School of Interdisciplinary Studies, University of Glasgow, Dumfries, UK
| | - Sam Quinn
- School of Interdisciplinary Studies, University of Glasgow, Dumfries, UK
| | | | | | - Merryn Gott
- School of Nursing, The University of Auckland, Auckland, New Zealand
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19
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Quinn S, Richards N, Gott M. Dying at home for people experiencing financial hardship and deprivation: How health and social care professionals recognise and reflect on patients’ circumstances. Palliat Care Soc Pract 2023; 17:26323524231164162. [PMID: 37025502 PMCID: PMC10071150 DOI: 10.1177/26323524231164162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
Background: International palliative care policy often views home as the most desirable location for end-of-life care. However, people living in more deprived areas can worry about dying in poor material circumstances and report more benefits from hospital admission at the end of life. There is increasing recognition of inequities in the experience of palliative care, particularly for people living in more deprived areas. Promoting an equity agenda in palliative care means building healthcare professionals’ capacity to respond to the social determinants of health when working with patients near the end of their life. Objectives: The purpose of this article is to present data which reveal how some health and social care professionals view home dying for people experiencing financial hardship and deprivation. Design: This work was framed by social constructionist epistemology. Methods: Semi-structured qualitative interviews ( n = 12) were conducted with health and social care professionals who support people at the end of life. Participants were recruited from one rural and one urban health board area in Scotland, UK. Data collection occurred between February and October 2021. Analysis: Thematic analysis was used to analyse the interview data. Discussion: Our findings suggest that healthcare staff relied on physical clues in the home environment to identify if people were experiencing financial hardship, found discussions around poverty challenging and lacked awareness of how inequities intersect at the end of life. Health professionals undertook ‘placing’ work to try and make the home environment a suitable space for dying, but some barriers were seen as insurmountable. There was recognition that increased partnership working and education could improve patient experiences. We argue further research is needed to capture the perspectives of individuals with direct lived experience of end-of-life care and financial hardship.
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Affiliation(s)
| | - Naomi Richards
- End of Life Studies Group, School of
Interdisciplinary Studies, Dumfries Campus, University of Glasgow, Dumfries,
UK
| | - Merryn Gott
- Te Ārai Research Group – Palliative Care &
End of Life, School of Nursing, University of Auckland, Auckland, New
Zealand
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20
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Moss RH, Hussain J, Islam S, Small N, Dickerson J. Applying the community readiness model to identify and address inequity in end-of-life care in South Asian communities. Palliat Med 2022; 37:567-574. [PMID: 36579846 PMCID: PMC10074746 DOI: 10.1177/02692163221146587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Individuals from minoritised ethnic backgrounds are less likely than individuals from the dominant ethnic group to access palliative care services and to have documented Advance Care Plans. They are more likely to be admitted to hospital in the last months of life. AIM To use the Community Readiness Model to identify the barriers that influence how South Asian communities access and use two new palliative care services. DESIGN The Community Readiness Model is a validated tool that measures the readiness of a community. Key stakeholders were asked to: (i) complete a questionnaire to assess South Asian communities' readiness to engage in advance care planning and, (ii) attend a focus group to explore their views on the communities' understandings of palliative and end-of-life care. SETTING/PARTICIPANTS Ten key stakeholders who held a variety of occupations within palliative and end-of-life care services were recruited from the community. FINDINGS The South Asian communities were found to be at the 'pre-planning' stage of readiness, despite initiatives to improve awareness. The readiness of the health system was found to be limited, with a narrow medical focus during advance care planning, poor integration of voluntary and community services and limited understanding of what people consider a 'good' death. CONCLUSIONS The Community Readiness Model allowed insight into the South Asian communities' awareness of and readiness (to use) palliative care services. Using the Community Readiness Model before service implementation allowed steps to be taken to avoid widening inequities in access and use of new services.
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Affiliation(s)
- Rachael H Moss
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Jamilla Hussain
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK.,Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Shahid Islam
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Neil Small
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Josie Dickerson
- Bradford Institute for Health Research, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
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21
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Robinson L, Trevors Babici L, Tedesco A, Spaner D, Morey T, Dosani N. Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation. Palliat Med 2022; 37:646-651. [PMID: 36576315 PMCID: PMC10074742 DOI: 10.1177/02692163221146812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness. AIM We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness. DESIGN Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator's role and the ways in which patient care was impacted. SETTING AND PARTICIPANTS This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients. RESULTS We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding. CONCLUSIONS These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.
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Affiliation(s)
- Lilian Robinson
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Leeann Trevors Babici
- Palliative Education and Care for the Homeless Program, Toronto, ON, Canada.,Second Mile Club, Kensington Health, Toronto, ON, Canada
| | - Alissa Tedesco
- Palliative Education and Care for the Homeless Program, Toronto, ON, Canada
| | - Donna Spaner
- Palliative Education and Care for the Homeless Program, Toronto, ON, Canada
| | - Trevor Morey
- Palliative Education and Care for the Homeless Program, Toronto, ON, Canada
| | - Naheed Dosani
- Palliative Education and Care for the Homeless Program, Toronto, ON, Canada
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22
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Buchman DZ, Lo S, Ding P, Dosani N, Fazelzad R, Furlan AD, Isenberg SR, Spithoff S, Tedesco A, Zimmermann C, Lau J. Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines. Palliat Med 2022; 37:426-443. [PMID: 36522840 PMCID: PMC9760505 DOI: 10.1177/02692163221143153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities. AIM To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs. DESIGN Scoping review. DATA SOURCES We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics. RESULTS Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma. CONCLUSIONS Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.
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Affiliation(s)
- Daniel Z Buchman
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada
| | - Samantha Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Philip Ding
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Naheed Dosani
- Department of Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada.,Division of Palliative Care, McMaster University, Hamilton, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Andrea D Furlan
- Toronto Rehab, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Work & Health, Toronto, ON, Canada
| | - Sarina R Isenberg
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Hospital, Toronto, ON, Canada
| | - Alissa Tedesco
- Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Palliative Medicine, University of Toronto, ON, Canada.,Division of Palliative Care, University Health Network, Toronto, ON, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Division of Palliative Care, University Health Network, Toronto, ON, Canada
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23
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Giesbrecht M, Mollison A, Whitlock K, Stajduhar KI. "Once you open that door, it's a floodgate": Exploring work-related grief among community service workers providing care for structurally vulnerable populations at the end of life through participatory action research. Palliat Med 2022; 37:558-566. [PMID: 36461158 PMCID: PMC10074740 DOI: 10.1177/02692163221139727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief. AIM To explore community service workers' experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports. DESIGN A community-based participatory action research methodology, informed by equity perspectives, was employed. SETTING/PARTICIPANTS In an urban center in western Canada, community service worker (primary) participants (n = 18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n = 48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n = 5) and evaluative interviews (n = 13) with participants were conducted. Structured observational field notes (n = 34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process. RESULTS During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief. CONCLUSIONS Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.
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Affiliation(s)
- Melissa Giesbrecht
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Ashley Mollison
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Kara Whitlock
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Kelli I Stajduhar
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada.,School of Nursing, University of Victoria, Victoria, BC, Canada
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24
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French M, Keegan T, Preston N. Facilitating equitable access to hospice care in socially deprived areas: A mixed methods multiple case study. Palliat Med 2022; 37:508-519. [PMID: 36380483 PMCID: PMC10074748 DOI: 10.1177/02692163221133977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is uncertainty about the factors influencing inequities in access to palliative care in socially deprived areas, including the role of service models and professional perceptions. AIM To explore the relationship between social deprivation and access to hospice care, including factors influencing access and professional experiences of providing care. DESIGN A mixed-methods multiple case study approach was used. Hospice referrals data were analysed using generalised linear mixed models and other regression analyses. Qualitative interviews with healthcare professionals were analysed using thematic analysis. Findings from different areas (cases) were compared in a cross-case analysis. SETTING The study took place in North West England, using data from three hospices (8699 hospice patients) and interviews with 42 healthcare professionals. RESULTS Social deprivation was not statistically significantly, or consistently, associated with hospice referrals in the three cases (Case 1, Incidence Rate Ratio 1.04, p = 0.75; Case 2, Incidence Rate Ratio 1.09, p = 0.15, Case 3, Incidence Rate Ratio 0.88, p = 0.35). Hospice data and interviews suggest the model of hospice care, including working relationship with hospitals, and the local nature of social deprivation influenced access. Circumstances associated with social deprivation can conflict with professional expectations within palliative care. CONCLUSION Hospice care in the UK can be organised in ways that facilitate referrals of patients from socially deprived areas, although uncertainty about what constitutes need limits conclusions about equity. Grounding professional narratives around expectations, responsibility, and choice in frameworks that recognise the sociostructural influences on end-of-life circumstances may help to foster more equitable palliative care.
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Affiliation(s)
- Maddy French
- Division of Health Research, Lancaster University, UK
| | | | - Nancy Preston
- Division of Health Research, Lancaster University, UK
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25
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Bowers SP, Chin M, O’Riordan M, Carduff E. The end of life experiences of people living with socio-economic deprivation in the developed world: an integrative review. BMC Palliat Care 2022; 21:193. [PMCID: PMC9636719 DOI: 10.1186/s12904-022-01080-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/19/2022] [Indexed: 11/07/2022] Open
Abstract
Background Those experiencing socioeconomic deprivation have poorer quality of health throughout their life course which can result in poorer quality of death – with decreased access to palliative care services, greater use of acute care, and reduced access to preferred place of care compared with patients from less deprived populations. Aim To summarise the current global evidence from developed countries on end-of-life experience for those living with socio-economic deprivation. Design Integrative review in accordance with PRISMA. A thorough search of major databases from 2010–2020, using clear definitions of end-of-life care and well-established proxy indicators of socio-economic deprivation. Empirical research describing experience of adult patients in the last year of life care were included. Results Forty studies were included from a total of 3508 after screening and selection. These were deemed to be of high quality; from a wide range of countries with varying healthcare systems; and encompassed all palliative care settings for patients with malignant and non-malignant diagnoses. Three global themes were identified: 1) multi-dimensional symptom burden, 2) preferences and planning and 3) health and social care interactions at the end of life. Conclusions Current models of healthcare services are not meeting the needs of those experiencing socioeconomic deprivation at the end-of-life. Further work is needed to understand the disparity in care, particularly around ensuring patients voices are heard and can influence service development and delivery.
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Affiliation(s)
- Sarah P Bowers
- grid.416266.10000 0000 9009 9462NHS Tayside and University of Dundee, Ninewells Hospital, Dundee, DD1 9SY UK
| | - Ming Chin
- grid.417145.20000 0004 0624 9990University Hospital Wishaw, 50 Netherton Street, Lanarkshire, ML2 0DP UK
| | - Maire O’Riordan
- grid.470550.30000 0004 0641 2540Marie Curie Hospice, 133 Balornock Road, Glasgow, G21 3US UK
| | - Emma Carduff
- grid.470550.30000 0004 0641 2540Marie Curie Hospice, 133 Balornock Road, Glasgow, G21 3US UK
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26
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Bérubé A, Tapp D, Dupéré S, Plaisance A, Bravo G, Downar J, Couture V. Do Socioeconomic Factors Influence Knowledge, Attitudes, and Representations of End-of-Life Practices? A Cross-Sectional Study. J Palliat Care 2022:8258597221131658. [PMID: 36237145 DOI: 10.1177/08258597221131658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Access to palliative and end-of-life (EOL) care might be influenced by knowledge, attitudes, and representations of these practices. Socioeconomic factors might then affect what people know about EOL care practices, and how they perceive them. This study aims to compare knowledge, attitudes, and representations regarding EOL practices including assisted suicide, medical assistance in dying, and continuous palliative sedation of adults, according to socioeconomic variables. METHODS A cross-sectional community-based questionnaire study featuring two evolving vignettes and five end-of-life practices was conducted in Quebec, Canada. Three sample subgroups were created according to the participants' perceived financial situation and three according to educational attainment. Descriptive analysis was used to compare levels of knowledge, attitudes, and representations between the subgroups. RESULTS Nine hundred sixty-six (966) people completed the questionnaire. Two hundred and seventy participants (28.7%) had a high school diploma or less, and 42 participants (4.4%) were facing financial hardship. The majority of respondents supported all end-of-life options and the loosening of eligibility requirements for medical assistance in dying. Differences between subgroups were minor. While respondents in socioeconomically disadvantaged subgroups had less knowledge about EOL practices, those with lower educational attainment were more likely to be in favor of medical assistance in dying, and less likely to favor continuous palliative sedation. CONCLUSIONS People living with situational social and economic vulnerabilities face multiple barriers in accessing health care. While they may have poorer knowledge about EOL practices, they have a positive attitude towards medical assistance in dying and assisted suicide, and a negative attitude towards continuous palliative sedation. This highlights the need for future research and interventions aimed at empowering this population and enhancing their access to EOL care.
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Affiliation(s)
- A Bérubé
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - D Tapp
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - S Dupéré
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
| | - A Plaisance
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - G Bravo
- Faculty of Medicine and Health Sciences, Sherbrooke University, Sherbrooke, QC, Canada
| | - J Downar
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - V Couture
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Axis, Research Center of the CHU de Québec-Université Laval, Quebec, QC, Canada
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27
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Bindley K, Lewis J, Travaglia J, DiGiacomo M. Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness. Palliat Med 2022; 37:543-557. [PMID: 36114642 DOI: 10.1177/02692163221122289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications. AIM To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations. DESIGN The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study. SETTING/PARTICIPANTS Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data. RESULTS Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage. CONCLUSIONS This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.
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Affiliation(s)
- Kristin Bindley
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia.,Supportive and Palliative Care, Western Sydney Local Health District, Mount Druitt, NSW, Australia
| | - Joanne Lewis
- School of Nursing and Health, Avondale University, Wahroonga, NSW, Australia.,School of Nursing and Midwifery, University of Technology Sydney, Ultimo, NSW, Australia
| | - Joanne Travaglia
- Health Services Management, School of Public Health, The University of Technology Sydney, Ultimo, NSW, Australia
| | - Michelle DiGiacomo
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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28
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Boschen K, Phelan C, Lawn S. NDIS Participants with Psychosocial Disabilities and Life-Limiting Diagnoses: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10144. [PMID: 36011776 PMCID: PMC9407781 DOI: 10.3390/ijerph191610144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 06/15/2023]
Abstract
This research aimed to map evidence about system supports and gaps for Australians with psychosocial disabilities and life-limiting diagnoses. A scoping review of available policy documents, academic, and grey literature was completed to discover key characteristics of this concept and provide context around the phenomenon. Our focus was on Australia's National Disability Insurance Scheme (NDIS), a key reform providing support to the disability population nationally. No peer-reviewed or grey literature was retrieved on the phenomena. Therefore, three lines of enquiry were developed: experiences of NDIS participants living with psychosocial disabilities; the death, dying, and palliative care supports and experiences of NDIS participants of any disability type; and the experiences for people living with severe and persistent mental illness (SPMI) and life-limiting diagnoses. Five themes were identified: (1) the person; (2) advocacy; (3) informal supports; (4) formal supports; and (5) existing research. NDIS participants living with SPMI and their informal and formal support systems are still struggling to navigate the NDIS. While there are no specific publications about their end-of-life experiences, people with SPMI often experience poor end-of-life outcomes. Rigorous research into their death, dying, and palliative care experiences is needed to inform improved support to them, including their end-of-life care.
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Affiliation(s)
- Kathy Boschen
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5050, Australia
| | - Caroline Phelan
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5050, Australia
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5050, Australia
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29
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Carter AJE, Harrison M, Kryworuchko J, Kekwaletswe T, Wong ST, Goldstein J, Warner G. Essential Elements to Implementing a Paramedic Palliative Model of Care: An Application of the Consolidated Framework for Implementation Research. J Palliat Med 2022; 25:1345-1354. [PMID: 35727113 DOI: 10.1089/jpm.2021.0459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Comfort care without transport to hospital was not traditionally a paramedic practice. The novel Paramedics Providing Palliative Care at Home Program includes a new clinical practice guideline, medications, a database to manage and share goals of care, and palliative care training. This study determined essential elements for implementation, scale, and spread of this Program. Methods: Deliberative dialogs, a qualitative method, were held with diverse stakeholders/experts in one province with the Program (Nova Scotia, March 2018) and one without (British Columbia, July 2018). The Consolidated Framework for Implementation Research (CFIR) informed the discussion guide and was used in a framework analysis. Four team members analyzed the data independently; themes were derived by consensus with the broader research team. Results: CFIR constructs framed several key elements. Inter-sectoral communication is critical but challenged by privacy concerns and the siloed structure of the health system. Locally adapted training is an essential characteristic of the intervention; cost is a factor. A shift in mindset away from traditional paramedic roles is required; this can be facilitated by paramedic champions and a positive implementation climate. Early engagement of diverse stakeholders and planning for sustainability is key. Conclusion: This framework analysis using CFIR constructs can guide successful scale and spread of the program. The constructs of Outer setting: Cosmopolitanism; Characteristics of the intervention: Adaptability; Inner Setting: Implementation climate; and Processes: Engagement, and Planning, emerged as essential.
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Affiliation(s)
- Alix J E Carter
- Emergency Health Services Nova Scotia, Halifax, Nova Scotia, Canada.,Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michelle Harrison
- Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Nova Scotia Health Halifax, Nova Scotia, Canada
| | - Jennifer Kryworuchko
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada.,School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tjingaita Kekwaletswe
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sabrina T Wong
- Center for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada.,School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judah Goldstein
- Emergency Health Services Nova Scotia, Halifax, Nova Scotia, Canada.,Division of EMS, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Grace Warner
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
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30
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Donald EE, Whitlock K, Dansereau T, Sands DJ, Small D, Stajduhar KI. A codevelopment process to advance methods for the use of patient-reported outcome measures and patient-reported experience measures with people who are homeless and experience chronic illness. Health Expect 2022; 25:2264-2274. [PMID: 35411709 PMCID: PMC9615092 DOI: 10.1111/hex.13489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 02/12/2022] [Accepted: 03/15/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction People who experience social disadvantage including homelessness suffer from numerous ill health effects when compared to the general public. Use of patient‐reported outcome measures (PROMs) and patient‐reported experience measures (PREMs) enables collection of information from the point of view of the person receiving care. Involvement in research and health care decision‐making, a process that can be facilitated by the use of PROMs and PREMs, is one way to promote equity in care. Methods This article reports on a codevelopment and consultation study investigating the use of PROMs and PREMs with people who experience homelessness and chronic illness. Data were analysed according to interpretative phenomenological analysis. Results Committee members with lived experience identified three themes for the role of PROMs and PREMs in health care measurement: trust and relationship‐building; health and quality of life; and equity, alongside specific recommendations for the design and administration of PROMs and PREMs. The codevelopment process is reported to demonstrate the meaningful investment in time, infrastructure and relationship‐building required for successful partnership between researchers and people with lived experience of homelessness. Conclusion PROMs and PREMs can be meaningful measurement tools for people who experience social disadvantage, but can be alienating or reproduce inequity if they fail to capture complexity or rely on hidden assumptions of key concepts. Patient or Public Contribution This study was conducted in active partnership between researchers and people with experience of homelessness and chronic illness, including priority setting for study design, data construction, analysis and coauthorship on this article.
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Affiliation(s)
- Erin E Donald
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, British Columbia, Canada.,Faculty of Human and Social Development, School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Kara Whitlock
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, British Columbia, Canada
| | | | | | | | - Kelli I Stajduhar
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, British Columbia, Canada.,Faculty of Human and Social Development, School of Nursing, University of Victoria, Victoria, British Columbia, Canada
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Bhadelia A, Oldfield LE, Cruz JL, Singh R, Finkelstein EA. Identifying Core Domains to Assess the "Quality of Death": A Scoping Review. J Pain Symptom Manage 2022; 63:e365-e386. [PMID: 34896278 DOI: 10.1016/j.jpainsymman.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/18/2021] [Accepted: 11/28/2021] [Indexed: 01/13/2023]
Abstract
CONTEXT There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines. OBJECTIVES Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems. METHODS PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles. RESULTS A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication. CONCLUSION The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.
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Affiliation(s)
- Afsan Bhadelia
- Department of Global Health and Population (A.B.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
| | | | - Jennifer L Cruz
- Department of Social and Behavioral Sciences (J.L.C.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ratna Singh
- Lien Centre for Palliative Care (R.S., E.A.F.), Duke-NUS Medical School, Singapore, Singapore
| | - Eric A Finkelstein
- Lien Centre for Palliative Care (R.S., E.A.F.), Duke-NUS Medical School, Singapore, Singapore
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A longevity society requires integrated palliative care models for historically excluded older people. THE LANCET. HEALTHY LONGEVITY 2022; 3:e227-e228. [PMID: 36098297 PMCID: PMC9594982 DOI: 10.1016/s2666-7568(22)00031-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022] Open
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Morberg Jämterud S. Acknowledging vulnerability in ethics of palliative care – A feminist ethics approach. Nurs Ethics 2022; 29:952-961. [PMID: 35225042 PMCID: PMC9289980 DOI: 10.1177/09697330211072361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patients in need of palliative care are often described as vulnerable. Being vulnerable can sometimes be interpreted as the opposite of being autonomous, if an autonomous person is seen as an independent, self-sufficient person who forms decisions independently of others. Such a dichotomous view can create a situation where one has experiences of vulnerability that cannot be reconciled with the central ethical principle of autonomy. The article presents a feminist ethical perspective on the conceptualisation of vulnerability in the context of palliative care. It does so through the lens of the concepts of inherent and pathogenic vulnerability from the taxonomy on vulnerability suggested by Mackenzie et al. To differentiate between forms of vulnerability, is important since even though vulnerability can be regarded as a shared life condition it can be the product of practices creating harm to the patient. The article also presents an analysis of how vulnerability can be included in the interpretation of the ethical principle of autonomy, in order to be relevant in palliative care where vulnerability is salient, namely, as relational autonomy. Furthermore, two practical implications for nursing practice are suggested. Firstly, to acknowledge vulnerability as a shared life condition one needs training in order to neither be overwhelmed by one’s own vulnerability, nor become invulnerable when facing vulnerability in others. Secondly, to foster relational autonomy includes navigating between the patient exercising their autonomy within a framework of relations, and shielding the patient from paternalistic practices. Nurses could be particularly suited for this role, which includes creating an environment which is open and supportive; navigating between patient, family and staff; seeing and acknowledging the complex situation in which patient autonomy is actually played out; and promoting patient autonomy.
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Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Technology and Social Change, Linköping University, Linköping, Sweden
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Horrill TC, Browne AJ, Stajduhar KI. Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology. Curr Oncol 2022; 29:186-192. [PMID: 35049692 PMCID: PMC8774995 DOI: 10.3390/curroncol29010018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.
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Affiliation(s)
- Tara C. Horrill
- School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada;
- Correspondence:
| | - Annette J. Browne
- School of Nursing, University of British Columbia, Vancouver, BC V6T 2B5, Canada;
| | - Kelli I. Stajduhar
- School of Nursing, University of Victoria, Victoria, BC V8P 5C2, Canada;
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Hansford L, Thomas F, Wyatt K. How does housing affect end-of-life care and bereavement in low-income communities? A qualitative study of the experiences of bereaved individuals and service providers in the United Kingdom. Palliat Care Soc Pract 2022; 16:26323524221110248. [PMID: 35832689 PMCID: PMC9272155 DOI: 10.1177/26323524221110248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/10/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Access to affordable, appropriate housing is one of the key social determinants of health, affecting well-being across the lifecourse. However, beyond a recognition that housing quality is linked to place of death, little is known about the ways in which housing status impacts social, emotional, and practical aspects of dying and bereavement. Method: The Checking Out project is a qualitative study aiming to explore the ways in which socio-economic status impacts people’s experiences of, and attitudes towards, death, dying, and bereavement in the United Kingdom. Qualitative interviews were carried out with 14 bereaved individuals with experience of poverty at end of life or in bereavement, and 15 professionals supporting individuals in low-income communities. Interviews were conducted via phone/video call, and data include experiences of end of life and bereavement both before and during the pandemic. Transcripts were examined using thematic analysis. Results: Housing emerged as an important factor affecting people’s experiences, with 7 of the 14 bereaved individuals and all except 1 of the professionals discussing housing-related issues. Participants described ways in which unsuitable housing and housing insecurity impacted practical aspects of dying but also emotional and social well-being at end of life. Housing-related issues affected both patients and their families, though families found it difficult to air these concerns when their relative was dying. Conclusion: The paper demonstrates how trusted professionals are able to advocate or address the issues faced by bereaved individuals and suggests implications for policy and practice. A greater awareness of the potential impact of housing status across public services, including healthcare practitioners, welfare support, and housing providers, could better support patients and practitioners to address these issues proactively. Housing providers and policy-makers should be included as key partners in collaborative public health approaches to palliative care.
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Affiliation(s)
- Lorraine Hansford
- Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, UK
| | - Felicity Thomas
- Wellcome Centre for Cultures and Environments of Health, University of Exeter, Queen’s Drive, Exeter, EX4 4QH, UK
| | - Katrina Wyatt
- Wellcome Centre for Cultures and Environments of Health, University of Exeter, Queen’s Drive, Exeter, EX4 4QH, UK
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Edwards D, Anstey S, Coffey M, Gill P, Mann M, Meudell A, Hannigan B. End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study). Palliat Med 2021; 35:1747-1760. [PMID: 34479457 PMCID: PMC8637363 DOI: 10.1177/02692163211037480] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all. AIM To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness. DESIGN A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches. DATA SOURCES Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary. RESULTS Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness. CONCLUSIONS Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.
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Affiliation(s)
- Deborah Edwards
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Sally Anstey
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Michael Coffey
- Department of Public Health, Policy and
Social Sciences, College of Human and Health Sciences, Swansea University, Swansea,
UK
| | - Paul Gill
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mala Mann
- Specialist Unit for Review Evidence,
University Library Services, Cardiff University, Cardiff, UK
| | - Alan Meudell
- Independent Service User Researcher,
Caerphilly, UK
| | - Ben Hannigan
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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37
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French M, Keegan T, Anestis E, Preston N. Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis. BMC Palliat Care 2021; 20:179. [PMID: 34802450 PMCID: PMC8606060 DOI: 10.1186/s12904-021-00878-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care. METHODS This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised. RESULTS Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care. CONCLUSION There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.
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Affiliation(s)
- Maddy French
- Division of Health Research, Lancaster University, Lancaster, UK.
| | - Thomas Keegan
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | | | - Nancy Preston
- Division of Health Research, Lancaster University, Lancaster, UK
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Rowley J, Richards N, Carduff E, Gott M. The impact of poverty and deprivation at the end of life: a critical review. Palliat Care Soc Pract 2021; 15:26323524211033873. [PMID: 34541536 PMCID: PMC8442481 DOI: 10.1177/26323524211033873] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.
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Affiliation(s)
- Jane Rowley
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | - Naomi Richards
- End of Life Studies Group, School of
Interdisciplinary Studies, University of Glasgow, Glasgow, UK
| | | | - Merryn Gott
- Professor, Te Ārai Palliative Care and End of
Life Research Group, School of Nursing, The University of Auckland, Private
Bag 92019, Auckland 1142, New Zealand
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"Everybody in this community is at risk of dying": An ethnographic exploration on the potential of integrating a palliative approach to care among workers in inner-city settings. Palliat Support Care 2021; 18:670-675. [PMID: 32378499 DOI: 10.1017/s1478951520000280] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE At the end of life, the need for care increases. Yet, for structurally vulnerable populations (i.e., people experiencing homelessness and poverty, racism, criminalization of illicit drug use, stigma associated with mental health), access to care remains highly inaccessible. Emerging research suggests that enhancing access to palliative care for these populations requires moving care from traditional settings, such as the hospital, into community settings, like shelters and onto the street. Thus, inner-city workers (ICWs) (e.g., housing support and community outreach) have the potential to play pivotal roles in improving access to care by integrating a "palliative approach to care" in their work. METHOD Drawing upon observational field notes and interview data collected for a larger critical ethnographic study, this secondary thematic analysis examines ICWs' (n = 31) experiences providing care for dying clients and garners their perspectives regarding the constraints and facilitators that exist in successfully integrating a palliative approach to care in their work. RESULTS Findings reveal three themes: (1) Approaches, awareness, and training; (2) Workplace policies and filling in the gaps; and (3) Grief, bereavement, and access to supports. In brief, ICWs who draw upon harm reduction strategies strongly parallel palliative approaches to care, although more knowledge/training on palliative approaches was desired. In their continuous work with structurally vulnerable clients, ICWs have the opportunity to build trusting relationships, and over time, are able to identify those in need and assist in providing palliative support. However, despite death and dying is an everyday reality of ICWs, many described a lack of formal acknowledgement by employers and workplace support as limitations. SIGNIFICANCE OF RESULTS Findings contribute promising practices for enhancing equitable access to palliative care for society's most vulnerable populations by prioritizing front-line workers' perspectives on how best to integrate a palliative approach to care where structurally vulnerable populations live and die.
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Amroud MS, Raeissi P, Hashemi SM, Reisi N, Ahmadi SA. Investigating the challenges and barriers of palliative care delivery in Iran and the World: A systematic review study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:246. [PMID: 34485543 PMCID: PMC8395877 DOI: 10.4103/jehp.jehp_1325_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/09/2020] [Indexed: 06/13/2023]
Abstract
Palliative care and terminal patients care centers have an important role in improving the physical and psychological state of the patient and their families and increasing their satisfaction and care providers. A literature search of online databases (PubMed, Scopus, Web of science, Cochrane library, and Google Scholar) was searched from January 1, 2000, to the end of April 2019, by using the appropriate English keywords. Furthermore, IranMedex, Barkat, and Magiran databases were searched for the Persian articles. We used Standards for Reporting Qualitative Research checklist to evaluate the articles quality. From 1328 articles, 166 were reviewed in depth with 13 satisfying our inclusion criteria. The findings of this study revealed a wide range of barriers and challenges to palliative care delivery. The identified barriers were: Cultural, social and organizational barriers, lack of resources, equipment and financing, attitudes and cultures, barriers related to the patient and the patient's family, related barriers providers, time and money, education, communication challenges, policies, insurance problems, safety, and crisis management. The results of the studies showed that there are various barriers and challenges such as economic, cultural, social, organizational, and communication related to palliative care. Given the identified barriers and challenges, it is suggested that to improve the delivery of palliative care, the health system policy-makers and planners consider a resource-appropriate and culturally appropriate framework for palliative care delivery.
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Affiliation(s)
- Mohammad Salimi Amroud
- Department of Health Services Management, Iran University of Medical Sciences, Tehran, Iran
| | - Pouran Raeissi
- Department of Health Services Management, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed-Masoud Hashemi
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nahid Reisi
- Department of Pediatric Hematology and Oncology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed-Ahmad Ahmadi
- Department of Health Services Management, Iran University of Medical Sciences, Tehran, Iran
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Kotwal AA, Cenzer IS, Waite LJ, Covinsky KE, Perissinotto CM, Boscardin WJ, Hawkley LC, Dale W, Smith AK. The epidemiology of social isolation and loneliness among older adults during the last years of life. J Am Geriatr Soc 2021; 69:3081-3091. [PMID: 34247388 DOI: 10.1111/jgs.17366] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/08/2021] [Accepted: 06/12/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Social isolation and loneliness are critical to the health of older adults, but they have not been well-described at the end of life. OBJECTIVES To determine the prevalence and correlates of social isolation and loneliness among older adults in the last years of life. DESIGN Nationally representative, cross-sectional survey. SETTING Health and Retirement Study, 2006-2016 data. PARTICIPANTS Adults age > 50 interviewed once in the last 4 years of life (n = 3613). MEASUREMENTS We defined social isolation using a 15-item scale measuring household contacts, social network interaction, and community engagement, and frequent loneliness using the 3-item UCLA Loneliness Scale. We used multivariable logistic regression to determine their adjusted prevalence by time prior-to-death and by subgroups of interest. RESULTS Approximately 19% experienced social isolation, 18% loneliness, and 5% both in the last 4 years of life (correlation = 0.11). The adjusted prevalence of social isolation was higher for individuals nearer to death (4 years: 18% vs 0-3 months: 27%, p = 0.05) and there was no significant change in loneliness (4 years: 19% vs 0-3 months: 23%, p = 0.13). Risk factors for both isolation and loneliness included (p < 0.01): low net-worth (Isolation: 34% vs 14%; Loneliness: 29% vs 13%), hearing impairment (Isolation: 26% vs 20%; Loneliness: 26% vs 17%), and difficulty preparing meals (Isolation: 27% vs 19%; Loneliness: 29% vs 15%). Factors associated with loneliness, but not social isolation, included being female, pain, incontinence, and cognitive impairment. CONCLUSIONS Social isolation and loneliness are common at the end of life, affecting 1 in 4 older adults, but few experience both. Rates were higher for older adults who were poor and experienced functional or sensory impairments. Results can inform clinical efforts to identify and address end-of-life psychosocial suffering and health policies which prioritize social needs at the end of life.
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Affiliation(s)
- Ashwin A Kotwal
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Irena S Cenzer
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Linda J Waite
- Department of Sociology, University of Chicago, Chicago, Illinois, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Carla M Perissinotto
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Louise C Hawkley
- National Opinion Research Center, University of Chicago, Chicago, Illinois, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope National Medical Center, Duarte, California, USA
| | - Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California, USA.,Geriatrics, Palliative, and Extended Care Service Line, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Maree P, Hughes R, Radford J, Stankovich J, Van Dam PJ. Integrating patient complexity into health policy: a conceptual framework. AUST HEALTH REV 2021; 45:199-206. [PMID: 33208225 DOI: 10.1071/ah19290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/19/2020] [Indexed: 11/23/2022]
Abstract
Objective Clinicians across all health professions increasingly strive to add value to the care they deliver through the application of the central tenets of people-centred care (PCC), namely the 'right care', in the 'right place', at the 'right time' and 'tailored to the needs of communities'. This ideal is being hampered by a lack of a structured, evidence-based means to formulate policy and value the commissioning of services in an environment of increasing appreciation for the complex health needs of communities. This creates significant challenges for policy makers, commissioners and providers of health services. Communities face a complex intersection of challenges when engaging with healthcare. Increasingly, complexity is gaining prominence as a significant factor in the delivery of PCC. Based on the World Health Organization (WHO) components of health policy, this paper proposes a policy framework that enables policy makers, commissioners and providers of health care to integrate a model of complexity into policy, subsequent service planning and development of models of care. Methods The WHO components of health policy were used as the basis for the framework. Literature was drawn on to develop a policy framework that integrates complexity into health policy. Results Within the framework, complexity is juxtaposed between the WHO components of 'vision', 'priorities' and 'roles'. Conclusion This framework, supported by the literature, provides a means for policy makers and health planners to conduct analyses of and for policy. Further work is required to better model complexity in a manner that integrates consumer needs and provider capabilities. What is known about the topic? There is a growing body of evidence regarding patient complexity and its impact on the delivery of health services, but there is little consideration of patient complexity in policy, which is an important consideration for service provision. What does this paper add? This paper presents an argument for the inclusion of patient complexity in health policy and provides a framework for how that might occur. What are the implications for practitioners? The inclusion of patient complexity in policy could provide a means for policy makers to consider the factors that contribute to patient complexity in service provision decisions.
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Affiliation(s)
- Peter Maree
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ; ; and Department of Health, 22 Elizabeth Street, Hobart, Tas. 7000, Australia; and Corresponding author.
| | - Roger Hughes
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ;
| | - Jan Radford
- General Practice, Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia.
| | - Jim Stankovich
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ; ; and Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Vic. 3004, Australia.
| | - Pieter Jan Van Dam
- Tasmanian School of Medicine, College of Health and Medicine University of Tasmania, Private Bag 34, Hobart, Tas. 7001, Australia. ;
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Chidiac C, El Zakhem A, Osman H, Yamout R. Recommendations to Improve Palliative Care Provision for Marginalized Populations: Summary of a Roundtable Discussion. J Palliat Med 2021; 24:1132-1138. [PMID: 34029127 DOI: 10.1089/jpm.2020.0548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Palliative care is increasingly recognized as fundamental to health and human dignity. However, a growing body of evidence highlights the variations in access to palliative care based on personal characteristics, belonging to a certain group, and socioeconomic background. Discriminatory attitudes and behaviors and lack of legal reform protecting the rights of marginalized populations are still common, particularly across Lebanon and the Middle East and North Africa region. This article presents a summary of a roundtable discussion organized by the Lebanese Medical Association for Sexual Health in collaboration with the Lebanese Center for Palliative Care-Balsam, focusing on improving palliative care provision for the following populations: prisoners; lesbian, gay, bisexual, and transgender people; refugees; migrant domestic workers; and people with substance use disorder. It also offers recommendations based on the key themes identified from the discussion, in the hope that they will guide the development of guidelines and policy to advance equity in palliative care provision for marginalized populations.
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Affiliation(s)
- Claude Chidiac
- Department of Palliative Care, Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Aline El Zakhem
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.,Lebanese Center for Palliative Care, Balsam, Beirut, Lebanon
| | - Hibah Osman
- Lebanese Center for Palliative Care, Balsam, Beirut, Lebanon.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rana Yamout
- Lebanese Center for Palliative Care, Balsam, Beirut, Lebanon.,Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon
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Schneider E, Dosani N. Retrospective Study of a Toronto-Based Palliative Care Program for Individuals Experiencing Homelessness. J Palliat Med 2021; 24:1232-1235. [PMID: 33794110 DOI: 10.1089/jpm.2020.0772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Individuals experiencing homelessness face increased morbidity and mortality. The Canadian Toronto-based Palliative Education and Care for the Homeless (PEACH) program was launched to better support those experiencing homelessness with life-limiting illness. Objective: To describe the population served by PEACH. Methods: A chart review of deceased clients from 2014 to 2017 was conducted. Results: Sixty-three individuals were included in the analysis. 85.7% were male and the median age was 60 years. 35.4% resided in shelters, 26.2% in supportive/transitional housing; only 3.2% were sleeping on the streets. Cancer was the most common diagnosis (61.9%). 58.7% of clients had mental health diagnoses and 61.9% endorsed substance use. Locations of death included palliative care unit and hospice (44.4%), hospital (23.8%), supportive housing (12.6%), and shelter (7.9%). Discussion: PEACH serves diverse clientele with unique care needs. This study will inform further palliative care research and interventions for those experiencing homelessness.
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Affiliation(s)
- Evan Schneider
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Naheed Dosani
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada
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Jerwood J, Ward G, Phimister D, Holliday N, Coad J. Lean in, don’t step back: The views and experiences of patients and carers with severe mental illness and incurable physical conditions on palliative and end of life care. PROGRESS IN PALLIATIVE CARE 2021. [DOI: 10.1080/09699260.2021.1887589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- J. Jerwood
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | - G. Ward
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
- Royal College of Occupational Therapists, London, UK
| | - D. Phimister
- School of Nursing, Midwifery and Health, Coventry University, Coventry, UK
| | - N. Holliday
- Faculty of Health and Life Sciences, Coventry University, Coventry, UK
| | - J. Coad
- School of Health Sciences, University of Nottingham, Nottingham, UK
- Nottingham University Hospital NHS Trust, Nottingham, UK
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van Dongen SI, Klop HT, Onwuteaka-Philipsen BD, de Veer AJ, Slockers MT, van Laere IR, van der Heide A, Rietjens JA. End-of-life care for homeless people in shelter-based nursing care settings: A retrospective record study. Palliat Med 2020; 34:1374-1384. [PMID: 32729794 PMCID: PMC7543021 DOI: 10.1177/0269216320940559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Homeless people experience multiple health problems and early mortality. In the Netherlands, they can get shelter-based end-of-life care, but shelters are predominantly focused on temporary accommodation and recovery. AIM To examine the characteristics of homeless people who reside at the end-of-life in shelter-based nursing care settings and the challenges in the end-of-life care provided to them. DESIGN A retrospective record study using both quantitative and qualitative analysis methods. SETTING/PARTICIPANTS Two Dutch shelter-based nursing care settings. We included 61 homeless patients who died between 2009 and 2016. RESULTS Most patients had somatic (98%), psychiatric (84%) and addiction problems (90%). For 75% of the patients, the end of life was recognised and documented; this occurred 0-1253 days before death. For 26%, a palliative care team was consulted in the year before death. In the three months before death, 45% had at least three transitions, mainly to hospitals. Sixty-five percent of the patients died in the shelter, 27% in a hospital and 3% in a hospice. A quarter of all patients were known to have died alone. Documented care difficulties concerned continuity of care, social and environmental safety, patient-professional communication and medical-pharmacological alleviation of suffering. CONCLUSIONS End-of-life care for homeless persons residing in shelter-based nursing care settings is characterised and challenged by comorbidities, uncertain prognoses, complicated social circumstances and many transitions to other settings. Multilevel end-of-life care improvements, including increased interdisciplinary collaboration, are needed to reduce transitions and suffering of this vulnerable population at the end of life.
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Affiliation(s)
- Sophie I van Dongen
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Hanna T Klop
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Centre for Palliative Care, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Centre for Palliative Care, Amsterdam UMC, VU University Amsterdam, Amsterdam, The Netherlands
| | - Anke Je de Veer
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Marcel T Slockers
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands.,CVD Havenzicht, Rotterdam, The Netherlands
| | - Igor R van Laere
- Netherlands Street Doctors Group (NSG), Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Gott M, Morgan T, Williams L. Gender and palliative care: a call to arms. Palliat Care Soc Pract 2020; 14:2632352420957997. [PMID: 33134926 PMCID: PMC7576896 DOI: 10.1177/2632352420957997] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 08/17/2020] [Indexed: 12/11/2022] Open
Abstract
There has been a systematic and largely unconscious neglect of gender in palliative care research, practice and policy. This is despite significant, although previously uncollated, evidence that gender influences almost all aspects of end-of-life preferences, experiences and care. The social situations of women, transgender people and men often differ from one another while also intersecting in complex ways with sex differences rooted in biology. If palliative care is to meet its aspiration of providing universal benefit, it urgently needs to address a range of gender inequalities currently (re)produced at the level of the laboratory all the way through to government departments. In this call to arms, we spotlight specific instances where gender inequalities have been documented, for example, regarding end-of-life caregiving, end-of-life intervention and palliative care access and benefit. We highlight how gender inequalities intersect with other social determinants of health including ethnicity and economic status to exacerbate situations of marginality. We conclude by offering some practical steps that can be taken to support the discipline to adopt a more critical gender lens to support more equitable research, policy and practice.
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Affiliation(s)
- Merryn Gott
- Professor, School of Nursing, Faculty of Medical
and Health Sciences, The University of Auckland, Private Bag 92019,
Auckland, New Zealand
| | - Tessa Morgan
- Department of Public Health and Primary Care and
Cambridge Institute of Public Health, University of Cambridge, Cambridge,
UK
| | - Lisa Williams
- School of Nursing, Faculty of Medical and Health
Sciences, The University of Auckland, Auckland, New Zealand
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Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Med Hypotheses 2020; 142:109727. [DOI: 10.1016/j.mehy.2020.109727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
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Stajduhar KI, Giesbrecht M, Mollison A, Dosani N, McNeil R. Caregiving at the margins: An ethnographic exploration of family caregivers experiences providing care for structurally vulnerable populations at the end-of-life. Palliat Med 2020; 34:946-953. [PMID: 32340556 PMCID: PMC7787672 DOI: 10.1177/0269216320917875] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND People experiencing structural vulnerability (e.g. homelessness, poverty, racism, criminalization of illicit drug use and mental health stigma) face significant barriers to accessing care at the end-of-life. 'Family' caregivers have the potential to play critical roles in providing care to these populations, yet little is known regarding 'who' caregivers are in this context and what their experiences may be. AIM To describe family caregiving in the context of structural vulnerability, to understand who these caregivers are, and the unique challenges, burdens and barriers they face. DESIGN Critical ethnography. SETTING/PARTICIPANTS Twenty-five family caregivers participated. Observational fieldnotes and semi-structured interviews were conducted in home, shelter, transitional housing, clinic, hospital, palliative care unit, community-based service centre and outdoor settings. RESULTS Family caregivers were found to be living within the constraints of structural vulnerability themselves, with almost half being street family or friends. The type of care provided varied greatly and included tasks associated with meeting the needs of basic survival (e.g. finding food and shelter). Thematic analysis revealed three core themes regarding experiences: Caregiving in the context of (1) poverty and substance use; (2) housing instability and (3) challenging relationships. CONCLUSION Findings offer novel insight into the experiences of family caregiving in the context of structural vulnerability. Engaging with family caregivers emerged as a missing and necessary palliative care practice, confirming the need to re-evaluate palliative care models and acknowledge issues of trust to create culturally relevant approaches for successful interventions. More research examining how 'family' is defined in this context is needed.
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Affiliation(s)
- Kelli I Stajduhar
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada.,School of Nursing, University of Victoria, Victoria, BC, Canada
| | - Melissa Giesbrecht
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Ashley Mollison
- Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | | | - Ryan McNeil
- BC Centre on Substance Use, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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D’Angelo D, Di Nitto M, Giannarelli D, Croci I, Latina R, Marchetti A, Magnani C, Mastroianni C, Piredda M, Artico M, De Marinis MG. Inequity in palliative care service full utilisation among patients with advanced cancer: a retrospective Cohort study. Acta Oncol 2020; 59:620-627. [PMID: 32148138 DOI: 10.1080/0284186x.2020.1736335] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Advanced cancer patients often die in hospital after receiving needless, aggressive treatment. Although palliative care improves symptom management, barriers to accessing palliative care services affect its utilisation, and such disparities challenge the equitable provision of palliative care. This study aimed to identify which factors are associated with inequitable palliative care service utilisation among advanced cancer patients by applying the Andersen Behavioural Model of Health Services Use.Material and methods: This was a retrospective cohort study using administrative healthcare data. A total of 13,656 patients residing in the Lazio region of Italy, who died of an advanced cancer-related cause-either in hospital or in a specialised palliative care facility-during the period of 2012-2016 were included in the study. Potential predictors of specialised palliative service utilisation were explored by grouping the following factors: predisposing factors (i.e., individuals' characteristics), enabling factors (i.e., systemic/structural factors) and need factors (i.e., type/severity of illness).Results: The logistic hierarchical regression showed that older patients (odds ratio [OR] = 1.45; <0.0001) of Caucasian ethnicity (OR = 4.17; 0.02), with a solid tumour (OR = 1.87; <0.0001) and with a longer survival time (OR = 2.09; <0.0001) were more likely to be enrolled in a palliative care service. Patients who lived farther from a specialised palliative care facility (OR = 0.13; <0.0001) and in an urban area (OR = 0.58; <0.0001) were less likely to be enrolled.Conclusion: This study found that socio-demographic (age, ethnicity), clinical (type of tumour, survival time) and organisational (area of residence, distance from service) factors affect the utilisation of specialised palliative care services. The fact that service utilisation is not only a function of patients' needs but also of other aspects demonstrates the presence of inequity in access to palliative care among advanced cancer patients.
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Affiliation(s)
| | - Marco Di Nitto
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Roma, Italy
| | - Diana Giannarelli
- Department of Biostatistical Unit, IRCCS-Regina Elena National Cancer Institute, Roma, Italy
| | - Ileana Croci
- IRCCS Ospedale Pediatrico “Bambino Gesù”, Roma, Italy
| | - Roberto Latina
- Department of Nursing Science and Midwifery, Sapienza University, Roma, Italy
| | - Anna Marchetti
- Department of Research Unit Nursing Science, Campus Bio-Medico di Roma University, Roma, Italy
| | - Caterina Magnani
- Local Health Authority “Roma 1”, Borgo Santo Spirito 3, Roma, Italy
| | | | - Michela Piredda
- Department of Research Unit Nursing Science, Campus Bio-Medico di Roma University, Roma, Italy
| | - Marco Artico
- Department of Palliative Care and Pain Therapy Unit, Azienda ULSS n.4 Veneto Orientale, Roma, Italy
| | - Maria Grazia De Marinis
- Department of Research Unit Nursing Science, Campus Bio-Medico di Roma University, Roma, Italy
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