Ethical challenges in family caregivers of patients with advanced cancer - a qualitative study

Improving Goal-Concordant Care in Intensive Care Unit Admissions from the Emergency Department in a Comprehensive Cancer Center

CONTEXT

As patients approach the end of life, discussion of their treatment goals is essential to avoid unnecessary suffering and deliver care in a manner consistent with their overall values.

OBJECTIVES

Implement a multipronged approach to improve the rates of advance care planning (ACP) documentation among providers admitting patients with cancer to the intensive care unit (ICU) from the emergency department (ED).

METHODS

We developed multiple interventions including the development of a best-practice advisory to alert providers when patients had previous do-not-resuscitate orders; standardization of ACP documentation; early oncologist involvement in goals-of-care conversations with patients; a survey of ED providers to identify barriers to success; and positive reinforcement strategies aimed at improving the rates of ACP documentation in patients admitted from the ED to the ICU.

RESULTS

Prior to our interventions, only 13% of patients admitted to the ICU from the ED had ACP notes. This percentage increased to 90% by the last month of our project.

CONCLUSION

Through our multipronged approach, we significantly improved the rates of ACP documentation among providers admitting patients from the ED to the ICU.

Exploration of clinical ethics consultation in Uganda: a case study of Uganda Cancer Institute

INTRODUCTION

Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESSs) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence about mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda.

METHODS

This phenomenological qualitative study utilized in-depth interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook.

RESULTS

The study revealed there was no formal committee or mechanism dedicated to resolving ethical dilemmas at the UCI. Instead, ethical dilemmas were addressed in six forums: individual consultations, tumor board meetings, morbidity and mortality meetings (MMMs), core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas.

CONCLUSION

The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

The CAREPAL-8: a short screening tool for multidimensional family caregiver burden in palliative care

BACKGROUND

Family caregivers of terminally ill and dying people do not only experience varying levels but also different dimensions of caregiver-related strain and burden. The aim of the study was to develop a short multidimensional screening tool for the detection of burden in family caregivers in palliative care.

METHODS

Family caregivers of cancer patients newly admitted to specialist inpatient palliative care (N = 232) completed questionnaires on psychological burden, quality of life, social support and need fulfillment. A latent class mixture model was used to identify discrete classes of family caregivers related to their multidimensional caregiver burden. Multinomial logistic regression analyses were performed to identify the most predictive items from a set of established questionnaires.

RESULTS

Four latent classes of family caregivers were identified: Currently stable caregivers (37%), Caregivers with unmet needs (20%), Psychologically burdened caregivers (30%), and High-risk caregivers (13%). Each of these classes describes a different risk profile of multidimensional family caregiver burden, although family caregivers exhibit high levels of distress across all classes. From a set of 48 items, we identified eight items that predicted the class membership best. These items represent the items of the novel multidimensional screening tool: The 8-item Screening Tool for Family Caregiver Burden in Palliative Care (CAREPAL-8). Except for social support, the items maintained fidelity to the conceptualization of multidimensional caregiver burden used in this study. A preliminary classification system was developed, which has yet to be validated.

CONCLUSIONS

This study represents the first step in the establishment of a practical, self-administered screening tool that might help healthcare providers to tailor caregiver care according to their burden in daily practice. Brevity of the 8-item tool might facilitate its use in routine clinical care.

Toward a new personalized psycho-social approach for the support of prostate cancer and their caregivers dyads: a pilot study

Introduction

Prostate cancer patients (PCP) often struggle with a significant emotional, physical, and social burden during the care-flow pathway. Noteworthy, PCP should not be considered a standalone patient, but someone who is connected with a relevant social environment and that is usually supported by a beloved one, the caregiver. The involvement of the caregivers through the care pathway might bring significant benefits both on the psychological and the treatment and decision-making side. The present pilot study aimed at preliminarily assessing quantitatively the psychological impact of a prostate cancer diagnosis on the degree of agreement of PCPs and their caregivers on medical decisions, coping resources and psychological distress levels.

Methods

16 PCP and their caregivers were enrolled in the study and fulfilled a battery of standardized questionnaires.

Results

Results showed low concordance in decision making styles and preferences in patients and their caregivers and that the dyads showed similar depression symptoms levels. Relevant features of the psychological needs of the analyzed dyads, such as need for information and support, also emerged.

Conclusion

On the basis of these preliminary results, guidelines for the construction of tailored brief psychological support interventions for PCP dyads are provided.

Mediating effect of social support between caregiver burden and quality of life among family caregivers of cancer patients in palliative care units

PURPOSE

To identify factors influencing the quality of life of family caregivers with terminal cancer in Chinese palliative wards and to test whether social support mediates the relationship between caregiver burden and caregiver quality of life.

METHODS

A cross-sectional study design was used. Sociodemographic data were collected and the Quality of Life Scale, the Caregiver Burden Scale, and the Social Support Rating Scale were administered to Chinese family caregivers from December 2021 to December 2022. The factors influencing quality of life and caregiver burden were examined using the Mann‒Whitney U test and the Kruskal‒Wallis H test. The mediating role of social support was assessed using the bootstrap method.

RESULTS

Family caregivers' quality of life in Chinese terminal cancer palliative units was related to caregivers' daily care time, the caregiver-patient relationship, and patient age. Caregiver quality of life was negatively associated with caregiver burden and positively associated with social support. In addition, social support mediated the relationship between caregiver burden and caregiver quality of life.

CONCLUSION

Social support mediated the impact of caregiver burden on caregiver quality of life. Family, society, and palliative care institutions should be integrated to take actions to reduce family caregiver burden, increase social support, and transfer the positive aspects of specific cultural contexts to the culture of palliative care in general to collaboratively cope with various problems related to end-stage cancer.

The Experience of Informal Newcomer Cancer Caregivers with Limited Language Proficiency: A Scoping Review

This scoping review explored what is known about the experiences of informal cancer caregivers (CGs) who are newcomers with limited language proficiency. A literature search was performed in seven databases and the search yielded 11,289 articles. After duplicate removal and title and abstract screening, 216 articles underwent full text review and 57 articles and were synthesized. Most studies (n = 41, 72%) were qualitative and were published in North America (n = 35, 61%). Most CG participants were female (69%) and only 19 studies explicitly identified the CG country of origin. Of those that did, 26% originated from Asia, with most migrating from East Asia. Significant challenges were experienced by newcomer CGs and chief among these were related to communication challenges with HCPs that were exacerbated by a lack of availability of medical interpreters and the complexity of oncology health information. Efforts are needed to better integrate newcomer CGs into cancer care.

Moral distress in carers for people with an intellectual disability who died during the COVID-19 pandemic, a template analysis extending the Barlem and Ramos model of moral distress

BACKGROUND

This article aims to understand moral distress in carers of people with an intellectual disability during the COVID-19 pandemic.

METHOD

Nine staff carers of seven people with an intellectual disability, who had been participants of the IDS-TILDA study in Ireland, who died during the COVID-19 pandemic participated in in-depth, semi-structured telephone interviews. Template analysis was used to analyze the interviews.

RESULTS

Obstructions in performing their duties left carers feeling powerless and experiencing moral conflict distress, moral constraint distress and moral uncertainty distress. Most managed to connect to the moral dimension in their work through peer support, understanding they fulfilled the wishes of the deceased, and/or thinking about how they or others did the best they could for the person they were caring for.

CONCLUSIONS

This research demonstrates that while restrictions may have been effective in reducing the spread of COVID-19, they were potentially damaging to carer wellbeing.

Caregiver Perspectives on the Benefits, Burdens, and Moral Distress of Participation in Cancer Clinical Trials

Caregivers often face critical decisions, burdens, and perceived benefits related to a loved one participating in cancer clinical trial (CCTs). The purpose of this analysis was to better understand caregivers' perceptions on the benefits and burdens of participation in cancer clinical trials. Using a qualitative descriptive design, interviews with 20 caregivers of patient-participants from a larger parent study were conducted. Three major themes emerged. The benefits of research participation focused on enhancing the potential for saving a loved one's life, improving quality of life, and holding altruistic intentions. The burden of research participation emphasized a loved one's suffering as well as physical, emotional, logistical, and financial burden to caregivers. Caregiver moral distress highlighted distressing ethical encounters, such as making decisions on research participation and navigating suboptimal care. Understanding caregiver perceptions is an important step in designing future CCTs that minimize burdens and maximize patient and caregiver health and family-centered care.

Changing dynamics of caregiving: a meta-ethnography study of informal caregivers' experiences with older immigrant family members in Europe

BACKGROUND

The population of Europe is ageing and becoming more ethnically diverse due to migration. Finding suitable long-term caring arrangements for older immigrants in Europe has been one of healthcare policymakers' concerns in the last decade. However, relatively few older people with an immigrant background live in long-term care facilities, and many prefer to be cared for by their family members. Little is known about immigrant family caregivers' experiences of caring for older family members and the support they need while providing care. This study aims to synthesize the qualitative literature exploring the experiences of individuals caring for older family members with immigrant backgrounds from Africa, Asia and South America living in Europe.

METHODS

We searched the electronic databases Medline Ovid, Embase Ovid, PsycInfo Ovid, SocIndex EBSCOhost, CINAHL EBSCOhost, Scopus, Social Care Online, ASSIA ProQuest, and Google Scholar for original, peer reviewed research articles, published in English from 2011 to 2022. The seven-step interpretive methodology in meta-ethnography developed by Noblit and Hare (1988) was followed for qualitative synthesis.

RESULTS

After assessing 4155 studies for eligibility criteria, 11 peer-reviewed articles were included in this review. The qualitative synthesis of these included articles resulted in four main themes: strong care norms for parents, the moral dilemma of continuing care, uneven care sharing, and the use of formal care services.

CONCLUSIONS

Caregiving dynamics are changing, both in terms of motivations and approaches to caregiving. Furthermore, there are gender disparities in the distribution of caregiving duties, particularly with women carrying the more significant burden of care. The care burden is further exacerbated by the lack of culturally sensitive formal services complementing the care needs of the ageing immigrants and their family caregivers. Therefore, those searching for alternatives to informal care should be met with appropriate health and care services in terms of language, culture, religion, and lifestyle, delivered in a non-judgmental way.

Caregiving and Shared Decision Making in Breast and Prostate Cancer Patients: A Systematic Review

BACKGROUND

A cancer diagnosis can impact patients' and caregivers' lives, posing different challenging situations. In particular, breast cancer and prostate cancer are two types of cancer involving families and especially spouses in challenges linked with the diagnosis and treatment process. Caregivers are usually involved in the treatment decision-making (TDM) process concerning patients' clinical pathway, cancer treatment, and ongoing therapies. To date, no contributions provide an exhaustive overview of the role of caregivers in cancer care and their involvement in the TDM process related to the therapies.

METHODS

We performed a systematic review of caregiver and patients experiences and perceptions of caregiver involvement in cancer TDM. Articles were searched on Public/Publisher MEDLINE (PubMed), Excerpta Medica Database (Embase), Medical Literature Analysis and Retrieval System Online (Medline), and American Psychological Association APA PsycINFO.

RESULTS

17 studies were included, 10 on prostate cancer and 7 on breast cancer. According to the reviewed studies, patients and caregivers experienced the cancer diagnosis with a sense of unity. Most patients preferred to have an active or collaborative role with caregivers in TDM, feeling it was important to consult or share the decision made with their caregivers. Caregivers preferred to collaborate with patients or let patients decide by themselves after considering their opinions. Caregiver involvement could have a positive influence on the patient's medical decisions, even if cancer diagnosis and treatments overwhelmed patients and caregivers.

CONCLUSIONS

These findings highlight the importance of using a perspective that focuses on the relationship between a patient and caregivers when they receive a cancer diagnosis and have to make a treatment decision. Targeting caregiver-patient dyads, rather than individuals, is important since a supported relationship could have a protective effect on psychological distress, quality of life (QOL), and relationship satisfaction. Moreover, dyads may benefit from interventions that focus on the needs of both the patient and caregiver.

The Persian version of Herth Hope Index in Iranian patients with cancer: A psychometric study

OBJECTIVES

Hope is a contextual concept that has significant effects on human well-being. This study aimed to evaluate the psychometric properties of the Persian version of the Herth Hope Index (P-HHI) among Iranian patients with cancer.

METHOD

This cross-sectional study was conducted on 320 patients with cancer from September to December 2020. After translating the HHI into Persian, content, convergent and discriminant, construct validity (exploratory and confirmatory factor analysis), and reliability of the P-HHI were assessed.

RESULTS

The results of exploratory factor analysis showed that the P-HHI was composed of two factors: Life Expectancy and Thinking Positive, which explained 55.20% of the total variance.

SIGNIFICANCE OF RESULTS

The research revealed that the P-HHI has acceptable validity and reliability, which can be used to measure the hope concept among Iranian patients with cancer.

Engaging African American family Caregivers in Developing a Culturally-responsive Interview Guide: A Multiphase Process and Approach

Qualitatively eliciting historically marginalized populations' beliefs, values, and preferences is critical to capturing information that authentically characterizes their experiences and can be used to develop culturally-responsive interventions. Eliciting these rich perspectives requires researchers to have highly effective qualitative interviewing guides, which can be optimized through community engagement. However, researchers have had little methodological guidance on how community member engagement can aid development of interview guides. The purpose of this article is to provide a series of steps, each supported by a case example from our work with African American family caregivers, for developing an interview guide through community engagement. We conclude by highlighting how involving historically marginalized community members in these early stages of research study development can build trust, research partnerships, and acknowledge their contribution to the development of new knowledge.

Family Caregivers' Experiences of Caring for Advanced Cancer Patients: A Qualitative Systematic Review and Meta-synthesis

BACKGROUND

Advanced cancers qualify as severe stressors to family caregivers (FCGs), which can negatively impact caregivers' psychological and physical well-being because of their association with high symptom burden, distress, and poor prognosis.

OBJECTIVE

This review aims to synthesize FCGs' experiences of caring for advanced cancer patients using a qualitative systematic review method.

METHODS

A comprehensive search was conducted in 7 databases from inception until July 2020. Two reviewers independently screened and assessed each study using Joanna Briggs Institute instruments and subsequently undertook the meta-aggregation approach to synthesize findings.

RESULTS

A total of 26 studies were included, refined to 37 findings, and integrated into 9 categories and 5 synthesized findings. When a loved one with advanced cancer faced deterioration near the end of their life, FCGs showed a tremendous sense of responsibility for care and concerted great efforts to alleviate their loved one's suffering while lacking effective professional support. Cultural beliefs had a great impact on FCGs' responsibility and role recognition. Ultimately, the caregiving helped FCGs achieve personal transcendence inherent in their unique experience.

CONCLUSIONS

Caring for advanced cancer patients is a unique, culture-specific experience marked by struggle. Effective professional support, including early palliative care, should be considered to improve the FCGs' experience of caring for advanced cancer patients. Cultural beliefs should be considered to understand and develop appropriate strategies to support FCGs.

IMPLICATIONS FOR PRACTICE

Healthcare providers need to ensure that individualized, multifaceted interventions considering FCGs' needs are delivered at the optimal time with the appropriate approach.

An Evaluation of Publicly Available Smartphone Apps to Support Unpaid Cancer Caregivers

CONTEXT

With advancements in mobile technology and increased access to smartphones, the use of Mobile Health applications (apps) has surged. These apps provide an innovative avenue for supporting cancer caregivers who face increasing burden and lack formal support; however, the quality of these apps has not been formally evaluated.

OBJECTIVES

Evaluate the quality, usefulness, therapeutic potential, and security of publicly available apps to support unpaid cancer caregivers in managing their roles and responsibilities.

METHODS

Cancer caregiving apps were identified through a search of the Apple and Google Play stores in October 2020. Two authors evaluated the apps using 1) the Mobile App Rating Scale (MARS) tool for quality, 2) complementary sections of Enlight for therapeutic persuasiveness and alliance, security and privacy, and 3) an unmet needs checklist to assess usefulness. Analyses were undertaken to identify high-scoring apps.

RESULTS

Overall, 24 apps were evaluated by two authors (MB, SW). Across the sample, the mean quality score (MARS) was adequate at 65.7% (3.3/5.0, SD = .5, range: 2.3-4.2). The combined score for therapeutic persuasiveness and alliance (Enlight) was fair at 60.7% (3.0/5.0, SD = .8, range: 1.1-4.5), and the privacy and security checklists yielded means of 79.3% (6.3/8.0, SD = 1.4, range: 50.0%-100.0%) and 41.3% (1.7/4.0, SD = 1.4, range: 0.0-100.0%), respectively. The unmet needs checklist was 43.2% (SD = 5.3, range: 9.4%-69.7%). A hierarchical cluster analysis identified 12 high scoring apps.

CONCLUSION

Superior cluster apps scored acceptably for quality and privacy and low for security and usefulness. Findings will assist clinicians, caregivers, and families identify apps to support cancer caregivers.

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Dealing with Family Conflicts in Decision-making in End-of-Life Care of Advanced Cancer Patients

PURPOSE OF REVIEW

The family plays a significant role in end-of-life care and decision-making with advanced cancer patients. This non-systematic review aims to summarize the family role and possible emerging conflicts and problems related to family involvement in decisions with advanced cancer patients.

RECENT FINDINGS

Four important domains were identified: (1) discordance between patients and caregivers' understanding of prognosis and goals of care; (2) internal family conflicts; (3) cultural differences regarding the role of the family in end-of life decision-making; (4) the burden on caregivers through caring for cancer patients. Based on the findings, we formulated some implications to consider for clinical practice. We suggest to involve the family in decision-making, to ascertain patients' wish for family involvement and if necessary, taking a mediator role between patients and their caregivers; to be aware of "invisible" family influence on patients' decisions; to assess systematically family burden and needs; to provide timely information, psychological support interventions and palliative care.

[Support for and involvement of family caregivers in Comprehensive Cancer Center - an Assessment of the Palliative Care Working Group within the network of Comprehensive Cancer Center funded by the German Cancer Aid]

BACKGROUND

According to current oncological guidelines, early integration of specialist palliative care (SPC) represents standard cancer care supporting not only the patients, but also their family caregivers. Data on the actual implementation in daily oncology practice in Germany are lacking.

METHODS

The Palliative Care Working Group of the network of Comprehensive Cancer Centers certified by the German Cancer Aid (CCC) assessed the implementation of measures for family caregiver support and involvement within the CCC/within SPC in the CCC/local outside the CCC in all 17 CCC locations.

RESULTS

In the CCC/in SPC psycho-oncological (100 %/94 %), social (94 %/100 %) and spiritual counselling of family caregivers (94 % each) as well as support for children with parental cancer (88 %/100 %) and information materials for family caregivers (88 % each) are well established. Training on nursing skills (77 %/94 %) and family conferences (59 %/88 %) are established more frequently within SPC than in the rest of the CCC. SOPs are rather rare (23 %/18 %) as well as screenings for family caregiver needs (0/24 %). Bereavement or self-help groups are with 82 % each more frequent locally outside the CCC. Psycho-oncological and social counselling as well as support for children with parental cancer were scored as most important (94 % each). For SPC, training on nursing skills and information materials were rated equally (94 % each). SOPs were rated as very/extremely important in 47 %/41 % and routine screening for family caregiver in 53 %/65 %.

CONCLUSION

In correspondence to their importance, psychosocial and spiritual counselling and support for children with parental cancer are well implemented in CCC. In SPC, training on nursing skills and family conferences are also well implemented. SOPs for family caregiver support and involvement as well as routine screenings for family caregiver needs have to be implemented urgently in the CCC.

How does spirituality manifest in family caregivers of terminally ill cancer patients? A qualitative secondary analysis

OBJECTIVE

Considering the risk of spiritual distress among terminally ill patients, experts long agree that spiritual care has to be an integral component of palliative care. Despite this consensus, the role of spirituality among family caregivers remains largely unexplored. We aimed to describe how spirituality manifests in the lived experience of family caregivers (FCs) in a palliative care context.

METHOD

As part of a secondary analysis, data derived from two qualitative primary studies on FCs' burdens and needs in the context of caring for a patient with a diagnosis of incurable cancer. Previously transcribed interviews were examined by means of a thematic analysis, transcending the focus of the primary studies to examine how spirituality arises and/or persists in the life of FCs from the time of diagnosis of incurable cancer up until bereavement.

RESULTS

Twenty-nine narratives were explored and all included spirituality as a relevant theme. Analysis revealed four aspects associated with the presence of spirituality among FCs' experiences: "Connectedness," "Religious Faith," "Transcendence," "Hope," and a fifth overarching aspect which we named "Ongoing integration of spiritual experience." Spirituality appeared as a multilayered phenomenon and was shaped individually among FCs' narratives.

SIGNIFICANCE OF RESULTS

In view of the results, exploring and discussing spirituality and underlying experiences in the situation as an FC seems likely to widen the perspective on FCs' problems and needs. Further research on spiritual needs among FCs of patients with incurable life-limiting cancer is deemed necessary.