Healthcare professionals' views of palliative care for American war veterans with non-malignant respiratory disease living in a rural area: a qualitative study

Military Veterans' End of Life: Supporting Them in Their Last Deployment

More than 600,000 U.S. Veterans die from illness each year. Clinicians in civilian settings are increasingly providing care to Veterans at end of life. Veteran care should be distinctive and individualized to meet their unique needs. There is limited information to guide civilian clinicians in providing care to Veterans at end of life. This article provides bio-psycho-social information to holistically guide Veteran healthcare and assist them with solace, respect, and serenity at end of life. Various options for end-of-life care are discussed, as well as specific concerns of women, lesbian, gay, bisexual, and transgender Veterans. Some end-of-life entitlements for all Veterans and sometimes their spouses/children are included.

Provider Perspectives on and Access to Palliative Care for Patients With Interstitial Lung Disease

BACKGROUND

Interstitial lung disease (ILD) results in profound symptom burden and carries high mortality. Palliative care (PC) is dedicated to improving quality of life in patients with serious illness. Early PC provision improves rates of advance care planning and symptom management in patients with ILD.

RESEARCH QUESTION

What are the current perspectives on PC among ILD providers, and what are the barriers to PC in ILD specialty centers?

STUDY DESIGN AND METHODS

A 24-question electronic survey was disseminated to providers at the 68 Pulmonary Fibrosis Foundation Care Centers across the United States from October 2020 to December 2020.

RESULTS

The survey was completed by 128 participants representing all 68 Pulmonary Fibrosis Foundation Care Center Network sites. Most respondents were physicians. Most providers exhibit good knowledge of, feel comfortable assessing a patient's readiness for, and agree with the need for PC for patients with ILD. Providers are most likely to refer to PC at objective disease and/or symptomatic progression rather than at initial diagnosis. In comparison with providers who report referring their patients to PC, providers who report rare referral are more likely to cite lack local PC availability (P < .01) and less likely to feel comfortable discussing prognosis/disease trajectory (P = .03) or feel it is important to address advance directives in ILD clinic (P = .02). There is a lack of standardized measures used to assess specific symptoms, overall symptom burden, or health-related quality of life across institutions. Discordance exists between self-reported and actual access to local inpatient and outpatient PC services.

INTERPRETATION

Most ILD providers use PC and are comfortable discussing PC. Barriers to PC identified in this survey include the following: perceived lack of local access to PC, lack of systematic tools to assess symptom burden, lack of established optimal timing of PC referral, and unclear need for specialized PC delivery.

Mindfulness as a well-being initiative for future nurses: a survey with undergraduate nursing students

BACKGROUND

Mindfulness can potentially positively impact well-being and resilience in undergraduate nursing students. The psychological well-being of such students undertaking clinical training is paramount to ensure optimal learning, and to equip them with skills to manage their wellbeing in future clinical practice. The aim of our study was to explore the views of undergraduate nursing students in relation to understanding and engaging with mindfulness, and how mindfulness could best be delivered within their university programme.

METHODS

An online survey was administered via a cloud-based student response system to a convenience sample of first year undergraduate nursing students completing a Bachelor of Science (BSc) Honours (Hons) degree in nursing at a University in the United Kingdom. Data were analysed using descriptive statistics and thematic analysis.

RESULTS

The survey achieved a response rate of 78% (n = 208). Seventy-nine percent of participants had heard of mindfulness and were interested in taking part in a mindfulness programme. Respondents reported that the ideal delivery of the programme would consist of weekly 45-min, in person group sessions, over a 6-week period. Respondents also indicated that a mobile application could potentially facilitate participation in the programme. Thematic analysis of open-ended comments, and free text, within the survey indicated 4 overarching themes: 1) Perceptions of what mindfulness is; 2) Previous mindfulness practice experiences; 3) Impact of mindfulness in nursing; 4) The need for a future well-being initiative for undergraduate nursing students.

CONCLUSIONS

Undergraduate nursing students perceived that a mindfulness programme has the potential to enhance well-being and future clinical practice. This student cohort are familiar with mindfulness and want more integrated within their undergraduate curriculum. Further research is required to examine the effectiveness of a tailored mindfulness intervention for this population that incorporates the use of both face-to-face and mobile delivery.

Mindfulness-Based Interventions for Undergraduate Nursing Students in a University Setting: A Narrative Review

(1) Introduction: Undergraduate (UG) nursing students are vulnerable to stress throughout their education, known to result in burnout, with high attrition rates of up to 33%. There is a growing body of evidence to suggest that mindfulness-based interventions are effective for the management of anxiety, depression and wellbeing, thereby reducing stress in healthcare provider populations. The aim of this narrative review was to synthesize and provide a critical overview of the current evidence in relation to mindfulness-based interventions for UG nursing students in a university setting. (2) Methods: A review of the literature was conducted in March 2020 and updated in May 2021, utilising the databases CINAHL, Medline and PsycINFO. (3) Results: Fifteen studies were included in the review, with three common themes identified: (i) the positive impact of mindfulness on holistic wellbeing, (ii) mindfulness-based techniques as a positive coping mechanism within academic and clinical practice, and (iii) approaches to the delivery of mindfulness-based interventions. (4) Conclusions: Mindfulness-based interventions are effective strategies for the management of stress, development of self-awareness and enhanced academic and clinical performance in undergraduate nursing students. No ideal approach to delivery or duration of these interventions was evident from the literature. Best practice in relation to delivery of mindfulness-based interventions for nursing students is recommended for future studies.

Examining Barriers and Facilitators to Palliative Care Access in Rural Areas: A Scoping Review

BACKGROUND

Despite the growth of palliative care (PC), access to PC remains challenging for rural Americans living with chronic diseases. Given the demand and benefits of PC, a comprehensive view of PC access would inform policymakers in developing PC services in rural areas.

OBJECTIVE

This scoping review aimed to understand the barriers and facilitators to PC access in rural areas from the voices of service users and service providers during the past decade.

METHODS

A scoping literature review was conducted from 2010 to 2020 using MEDLINE, CINAHL, and PsychINFO databases. Results: Twenty-eight studies met inclusion criteria. Barriers to PC access in rural areas mostly arose in structural issues: (1) the inadequate knowledge and awareness of PC among both service users and providers and (2) the poorly structured PC system. Other barriers included communication gaps/challenges between providers and patients/families and cultural barriers. The facilitators mainly originated in patients/families' connectedness with local providers and with other social networks such as friends.

CONCLUSIONS

These findings highlight the need for funding support to increase provider competency, service availability and accessibility, and the public knowledge and awareness of PC in rural areas. A holistic and tailored PC model that standardizes care delivery, referral and coordination, including family caregiver support programs, can improve care access. Future practice and research are warranted to implement and evaluate innovative approaches, such as a coordinated community-based approach, to the successful integration of PC in rural communities.

Palliative Care Initiation in Chronic Obstructive Pulmonary Disease: Prognosis-Based, Symptoms-Based or Needs-Based?

The absence or late initiation of palliative care (PC) in chronic obstructive pulmonary disease (COPD) is multidimensional. To provide palliative care from the moment of COPD diagnosis remains utopic. Even the advanced forms or the end-of-life stages benefit late or never from these services. In this context, the research questions for the present systematic review were focused on the prognosis variables or multicomponent indices in COPD patients alongside the symptoms and unmet needs, which may be useful for the palliative care initiation. The aim was to help clinicians to identify not only the tools reliable to predict poor survival in COPD patients but also to identify the criteria for appropriateness for early palliative care onset. The search included systematic reviews and reviews published in English in the PUBMED database from Jan 1, 2015 to Jan 6, 2020. From a total of 202 findings, after applying filters, using additional sources, and eliminating duplicates, the search strategy screened 16 articles, out of which 10 were selected and included. A Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) flow diagram was constructed. The main domains identified as barriers in providing palliative care in COPD patients were complex: from the prognosis difficulties to the prognostic variables and scores proposed for initiating PC; from the troublesome symptoms or the unidimensional symptom tools to the unmet needs of COPD patients. The review concluded that none of the existing prognostic variables and multicomponent indices are reliable enough to exclusively predict poor survival in COPD patients and the decision to initiate PC should be rather based on the presence of refractory symptoms and patients’ unmet needs and preferences. Despite the current advances, the ideal model to initiate palliative care from the moment COPD is diagnosed is a goal for clinicians trained in, and capable of providing palliative care in any COPD patient.

A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease

Background: Guidelines recommend that pulmonary clinicians involve palliative care in chronic obstructive pulmonary disease (COPD); however, integration before advanced stage, that is, early palliative care, is rare. Objective: To explore and compare pulmonary and palliative care clinician perspectives on barriers, facilitators, and potential referral criteria for early palliative care in COPD. Design: Qualitative descriptive formative evaluation study. Setting/Subjects: Pulmonary and palliative care clinicians at a tertiary academic medical center. Measurements: Transcribed interviews were thematically analyzed by specialty to identify within- and across-specialty perspectives on barriers, facilitators, and referral criteria. Results: Twelve clinicians (n = 6 pulmonary, n = 6 palliative care) participated. Clinicians from both specialties agreed that early palliative care could add value to disease-focused COPD care. Perspectives on many barriers and facilitators were shared between specialties along broad educational, clinical, and operational categories. Pulmonary and palliative care clinicians shared concerns about the misconception that palliative care was synonymous to end-of-life care. Pulmonologists were particularly concerned about the potential risks of opioids and benzodiazepines in COPD. Both specialties stressed the need for clearly defined roles, consensus referral criteria, and novel delivery models. Although no single referral criterion was discussed by all, frequent hospitalizations and emotional symptoms were raised by most across disciplines. Multimorbidity and poor prognosis were discussed only by palliative care clinicians, whereas medication adherence was discussed only by pulmonary clinicians. Conclusions: Pulmonary and palliative care clinicians supported early palliative care in COPD. Continued needs include addressing pulmonologists' misconceptions of palliative care, establishing consensus referral criteria, and implementing novel early palliative care models.

End-of-life care in rural general practice: how best to support commitment and meet challenges?

BACKGROUND

Few studies have specifically assessed the scope, nature and challenges of palliative and end-of-life care in rural general practice. These knowledge gaps limit the development of evidence-based policies and services for patients in the last months of life. This study aimed to explore the perspectives of general practitioners (GPs) and other stakeholders on rural GPs' involvement and challenges in providing palliative and end-of-life care in regional Australia.

METHODS

A qualitative study involving five focus groups with 26 GPs based in rural/regional Western Australia together with 15 individual telephone interviews with four GPs and 11 other stakeholders involved in end-of-life care across Australia.

RESULTS

The rural GPs' central role in end-of-life care was recognized by the majority of participants but multiple challenges were also identified. Some challenges were comparable to those found in urban settings but others were more pronounced, including resource limitations and lack of training. Inappropriate payment models discouraged GPs' involvement in some aspects of end-of-life care, such as case conferences and home visits. Compared to GPs in urban settings, those in rural/regional communities often reported closer doctor-patient relationships and better care integration and collaboration. These positive aspects of care could be further developed to enhance service provision. Our study highlighted the importance of regular interactions with other professionals and patients in providing end-of-life care, but many GPs and other stakeholders found such interactions more challenging than the more "technical" aspects of care.

CONCLUSIONS

Rural/regional GPs appear to be disproportionately affected by inappropriate payment models and limited resources, but may benefit from closer doctor-patient relationships and better care integration and collaboration relative to urban GPs. Systematic collection of empirical data on GP management at end-of-life is required to build on these strengths and address the challenges.