Social class and access to specialist palliative care services

Access for Cancer Caregivers to Education and Support for Shared Decision Making (ACCESS) intervention: a cluster cross-over randomised clinical trial

OBJECTIVES

The purpose of this study was to test an intervention named ACCESS (Access for Cancer Caregivers to Education and Support for Shared Decision Making). The intervention uses private Facebook support groups to support and educate caregivers, preparing them to participate in shared decision-making during web-based hospice care plan meetings. The overall hypothesis behind the study was that family caregivers of hospice patients with cancer would experience lower anxiety and depression as a result of participating in an online Facebook support group and shared decision-making with hospice staff in a web-based care plan meeting.

METHODS

This is a cluster cross-over randomised three-arm clinical trial where one group participated in both the Facebook group and the care plan team meeting. A second group participated only in the Facebook group and the third group was a control group and received usual hospice care.

RESULTS

There were 489 family caregivers who participated in the trial. There were no statistically significant differences between the ACCESS intervention group and the Facebook only or the control group on any outcome. The participants in the Facebook only group, however, experienced a statistically significant decrease in depression compared with the enhanced usual care group.

CONCLUSIONS

While the ACCESS intervention group did not experience significant improvement in outcomes, caregivers assigned to the Facebook only group showed significant improvement in depression scores from baseline as compared with the enhanced usual care control group. Further research is needed to understand the mechanisms of action leading to reduced depression.

Socio-economic factors affecting the academic performance of private university students in Bangladesh: a cross-sectional bivariate and multivariate analysis

Education is considered the most significant factor in producing human resource developments in terms of social, cultural, technological, economic, and overall national perspectives. Higher education is influenced by several factors that affect the quality of students' education and outcomes. Most students in Bangladesh study at private universities from various socioeconomic conditions. Some of the factors have restricted their ability to attain higher education and as a result, impacted their academic performance. The goal of this study was to explore those socioeconomic factors affecting the academic performance of private university students in Bangladesh. The primary dataset was collected through an online survey from three private universities in Bangladesh named Varendra University (VU), Daffodil International University (DIU), and City University (CU). The Chi-square tests indicate that the age, gender, studying on a subject of their own choice, getting the right direction to make studying comfortable, consulting with the teacher about learning, family status, etc. variables significantly impacted their cumulative grade point average (CGPA). Relationships with parents and the opportunity to share opinions with parents were also significantly associated with their results. According to the multinomial logistic regression model age, gender, employment status, choice of own study field, getting the right direction, previous academic result, consultation with teachers, father's annual income, family status, and relationship with parents are found to be statistically significant determinants of academic performance. Considering the reality and outcomes of this study, to improve academic performance, parental involvement needs to be increased, and they must provide financial and material support to their offspring for their academic success. Moreover, for achieving a satisfactory CGPA, the students need to build friendly relationships with their parents and have regular consultations with their teachers as well.

Hospice care access inequalities: a systematic review and narrative synthesis

BACKGROUND

Inequalities in access to hospice care is a source of considerable concern; white, middle-class, middle-aged patients with cancer have traditionally been over-represented in hospice populations.

OBJECTIVE

To identify from the literature the demographic characteristics of those who access hospice care more often, focusing on: diagnosis, age, gender, marital status, ethnicity, geography and socioeconomic status.

DESIGN

Systematic literature review and narrative synthesis.

METHOD

Searches of Medline, PsycINFO, CINAHL, Web of Science, Assia and Embase databases from January 1987 to end September 2019 were conducted. Inclusion criteria were peer-reviewed studies of adult patients in the UK, Australia, New Zealand and Canada, receiving inpatient, day, outpatient and community hospice care. Of the 45 937 titles retrieved, 130 met the inclusion criteria. Narrative synthesis of extracted data was conducted.

RESULTS

An extensive literature search demonstrates persistent inequalities in hospice care provision: patients without cancer, the oldest old, ethnic minorities and those living in rural or deprived areas are under-represented in hospice populations. The effect of gender and marital status is inconsistent. There is a limited literature concerning hospice service access for the LGBTQ+ community, homeless people and those living with HIV/AIDS, diabetes and cystic fibrosis.

CONCLUSION

Barriers of prognostic uncertainty, institutional cultures, particular needs of certain groups and lack of public awareness of hospice services remain substantial challenges to the hospice movement in ensuring equitable access for all.

Mixed methods analysis of hospice staff perceptions and shared decision making practices in hospice

PURPOSE

Shared decision making has been a long-standing practice in oncology and, despite a lack of research on the subject, is a central part of the philosophical foundation of hospice. This mixed methods study examined the perceptions of staff regarding shared decision making and their use of shared decision elements in hospice interdisciplinary team meetings.

METHODS

The revised Leeds Attitude to Concordance scale (LatConII) was used to measure the attitudes of hospice staff toward shared decision making. Field notes and transcripts of hospice interdisciplinary team meetings that included family caregivers as participants were coded to identify 9 theory-driven shared decision making elements. The results were mixed in a matrix analysis comparing attitudes with practice. Three transcripts demonstrate the variance in the shared decision making process between hospice teams.

RESULTS

Hospice staff reported overall positive views on shared decision making; however, these views differed depending on participants' age and position. The extent to which staff views were aligned with the observed use of shared decision making elements in hospice interdisciplinary team meetings varied.

CONCLUSION

Policy and practice conditions can make shared decision making challenging during hospice interdisciplinary team meetings despite support for the process by staff.

TRIAL REGISTRATION

This study is a sub-study of a parent study registered with clinicaltrials.gov (NCT02929108).

Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis

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.

Clinical and Socio-demographic Profile of Hospice Admissions: Experience from New Delhi

Background:

Our hospice caters to referrals from the wide areas in the northern Indian territory. A descriptive analysis of hospice admissions can bring to light, the status of palliative care in the region overall.

Aim:

The aim was to assess the clinical and demographic profile of hospice admissions in New Delhi during the time period 2016–2017.

Methods:

Hospice admission records from the calendar year 2016 were digitized from paper charts, and statistical analysis was carried out using SPSS v21. Patient and caregiver demographic profile and dominant referral and utilization patterns were retrospectively assessed.

Results:

One hundred and fifty-four admissions (mean age 51.8 ± 15 years; 60% females) were recorded. Up to one-third of the patients (48, 31%) were single at the time of admission. Majority of the patients had below 10^th grade literacy level (116, 75.3%) and belonged to low socioeconomic status. Two large tertiary care centers were the most common referrers (54.6%). The top three diagnoses were head-and-neck cancers (56, 36.4%), gastrointestinal cancers (27, 17.5%), and metastatic breast cancer (23, 14.9%). Major patient-reported debilities were pain (73%), dysphagia (51%), and incontinence (45%). The mean duration from diagnosis to hospice referral was 2.7 ± 0.7 years. Majority of the patients (76%) reported to have undergone some form of oncologic treatment. Up to two-thirds of the patients received opioids with or without additional supportive care.

Conclusion:

Pain, dysphagia, and incontinence were the most common reasons for hospice referral, with incontinence being significantly correlated with the divorced status. There were no differences in the prevalence of other symptoms with relation to the marital status. Data on hospice utilization patterns in India are limited to pilot experiences. More data are needed to drive national-level policies.

Optimal care at the end of life (OPAL): study protocol of a prospective interventional mixed-methods study with pretest-posttest-design in a primary health care setting considering the view of general practitioners, relatives of deceased patients and health care stakeholders

Background

At the end of life, about 85–90% of patients can be treated within primary palliative care (PC) provided by general practitioners (GPs). In Germany, there is no structured approach for the provision of PC by GPs including a systematic as well as timely identification of patients who might benefit from PC, yet. The project “Optimal care at the end of life” (OPAL) focusses on an improvement of primary PC for patients with both oncological and non-oncological chronic progressive diseases in their last phase of life provided by GPs and health care services.

Methods

OPAL will take place in Hameln-Pyrmont, a rural region in Lower Saxony, Germany. Target groups are (a) GPs, (b) relatives of deceased patients and (c) health care providers. The study follows a three-phase approach in a mixed-methods and pre-post design. In phase I (baseline, t₀) we explore the usual practice of providing PC for patients with chronic progressive diseases by GPs and the collaboration with other health care providers. In phase II (intervention) the Supportive and Palliative Care Indicators Tool (SPICT) for the timely identification of patients who might benefit from PC will be implemented and tested in general practices. Furthermore, a public campaign will be started to inform stakeholders, to connect health care providers and to train change agents. In phase III (follow-up, t₁) we investigate the potential effect of the intervention to evaluate differences in the provision of PC by GPs and to convey factors for the implementation of SPICT in general practices.

Discussion

The project OPAL is the first study to implement the SPICT-DE regionwide in general practices in Germany. The project OPAL may contribute to an overall optimisation of primary PC for patients in Germany by reducing GPs’ uncertainty in initiating PC, by consolidating their skills and competencies in identifying patients who might benefit from PC, and by improving the cooperation between GPs and different health care stakeholders.

Trial registration

The study was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; trial registration number: DRKS00015108; date of registration: 22th of January 2019).

Socioeconomic factors affecting access to preferred place of death: A qualitative evidence synthesis

BACKGROUND

Existing quantitative evidence suggests that at a population level, socioeconomic factors affect access to preferred place of death. However, the influence of individual and contextual socioeconomic factors on preferred place of death are less well understood.

AIM

To systematically synthesise the existing qualitative evidence for socioeconomic factors affecting access to preferred place of death in the United Kingdom.

DESIGN

A thematic synthesis of qualitative research.

DATA SOURCES

Cochrane Library, MEDLINE, Embase, CINAHL, ASSIA, Scopus and PsycINFO databases were searched from inception to May 2018.

RESULTS

A total of 13 articles, reporting on 12 studies, were included in the synthesis. Two overarching themes were identified: 'Human factors' representing support networks, interactions between people and decision-making and 'Environmental factors', which included issues around locations and resources. Few studies directly referenced socioeconomic deprivation. The main factor affecting access to preferred place of death was social support; people with fewer informal carers were less likely to die in their preferred location. Other key findings included fluidity around the concept of home and variability in preferred place of death itself, particularly in response to crises.

CONCLUSION

There is limited UK-based qualitative research on socioeconomic factors affecting preferred place of death. Further qualitative research is needed to explore the barriers and facilitators of access to preferred place of death in socioeconomically deprived UK communities. In practice, there needs to be more widespread discussion and documentation of preferred place of death while also recognising these preferences may change as death nears or in times of crisis.

Determinants of Home Death in Patients With Cancer: A Population-Based Study in Ontario, Canada

AIM

To determine factors associated with home death in patients with cancer in Ontario, particularly to assess the association between death at home and (1) patients' rural/urban residence and (2) neighborhood income in urban areas.

MATERIALS AND METHODS

We conducted a retrospective cross-sectional study in Ontario (2003-2010) using linked administrative databases. In order to account for clustering phenomenon, multivariable generalized estimating equation model was used to evaluate factors associated with home death. Analysis was performed in both rural and urban areas. For urban areas, neighborhood income was tested as a determinant of the place of death.

RESULTS

A total of 193 783 deaths were analyzed, 9.1% of which occurred at home. In urban areas, home death was more likely for patients living in richer neighborhoods (odds ratio 1.69 for the highest compared to lowest neighborhood income quintile, 95% confidence interval: 1.54-1.86). The odds of dying at home when living in a rural area were no different from those living in the poorest urban neighborhood. Other variables associated with lower odds of home death were comorbidity index, certain cancers, and year of death.

CONCLUSION

The likelihood of dying at home significantly increases with living in higher-income urban neighborhoods and decreases with rural residence. Urban neighborhoods with lowest income have odds of home death similar to rural areas. These findings underline the importance of targeting proper populations for public support at the end of life.

The development of a spatial palliative care index instrument for assessing population-level need for palliative care services

We developed an index to measure potential need for palliative care services (PCIX). This is an instrument that enables spatial identification of potential population-level need for palliative care services and can be developed using census data. Four indicators of potential need for palliative care services -age, sex, living arrangement, socio-economic status (SES)-were used to produce composite potential need scores for DAs. Scores were graphically mapped, producing a spatial delineation of relative need for end-of-life services. To assess the benefit of combining multiple variables to define potential need, PCIX resolution was compared to general SES-based delineations of need. PCIX scores and maps were generated for all DAs, revealing spatial variability in potential need for palliative care services (PCS). Comparison of PCIX maps to those based on purely on SES indicated that use of variables specifically linked to palliative need resulted in more precise delineations of potential populations in need of PCS. Using composite scores - based on freely available census data - to spatially assess potential need for palliative care services can provide critical data for decision makers charged with rationalizing service locations and service capacity.

Admittance to specialized palliative care (SPC) of patients with an assessed need: a study from the Danish palliative care database (DPD)

BACKGROUND

Admittance to specialized palliative care (SPC) has been discussed in the literature, but previous studies examined exclusively those admitted, not those with an assessed need for SPC but not admitted. The aim was to investigate whether admittance to SPC for referred adult patients with cancer was related to sex, age, diagnosis, geographic region or referral unit.

MATERIAL AND METHODS

A register-based study with data from the Danish Palliative Care Database (DPD). From DPD we identified all adult patients with cancer, who died in 2010-2012 and who were referred to and assessed to have a need for SPC (N = 21,597).The associations were investigated using logistic regression models, which also evaluated whether time from referral to death influenced the associations.

RESULTS

In the adjusted analysis, we found that admittance was higher for younger patients [e.g., 50-59 versus 80 + years: odds ratio (OR) = 2.03; 1.78-2.33]. There was lower odds of admittance for patients with hematological malignancies and patients from two regions: Capital Region of Denmark and Region of Southern Denmark. Lower admittance among men and patients referred from hospital departments was explained by later referral.

CONCLUSIONS

In this first nationwide study of admittance to SPC among patients with a SPC need, we found difference in admittance according to age, diagnosis and region. This indicates that prioritization of the limited resources means that certain subgroups with a documented need have reduced likelihood of admission to SPC.

Dying in hospital: socioeconomic inequality trends in England

Objective

To describe trends in socioeconomic inequality in the proportion of deaths occurring in hospital, during a period of sustained effort by the NHS in England to improve end of life care.

Methods

Whole-population, small area longitudinal study involving 5,260,871 patients of all ages who died in England from 2001/2002 to 2011/2012. Our primary measure of inequality was the slope index of inequality. This represents the estimated gap between the most and least deprived neighbourhood in England, allowing for the gradient in between. Neighbourhoods were geographic Lower Layer Super Output Areas containing about 1500 people each.

Results

The overall proportion of patients dying in hospital decreased from 49.5% to 43.6% during the study period, after initially increasing to 52.0% in 2004/2005. There was substantial ‘pro-rich’ inequality, with an estimated difference of 5.95 percentage points in the proportion of people dying in hospital (confidence interval 5.26 to 6.63), comparing the most and least deprived neighbourhoods in 2011/2012. There was no significant reduction in this gap over time, either in absolute terms or relative to the mean, despite the overall reduction in the proportion of patients dying in hospital.

Conclusions

Efforts to reduce the proportion of patients dying in hospital in England have been successful overall but did not reduce inequality. Greater understanding of the reasons for such inequality is required before policy changes can be determined.

Does place of death vary by deprivation for patients known to specialist palliative care services?

OBJECTIVES

Referral to, and usage of, specialist palliative care (SPC) services are not equitable and social deprivation may be a contributory factor in this. Deprivation may also affect the place of death of patients with cancer. No study, however, has investigated whether inequalities persist following referral to SPC services. This study investigates whether place of death varies by deprivation for patients known to SPC services.

METHODS

Place of death and postcode were obtained for 485 consecutive patients known to SPC services within NHS Lothian who died in 2014-2015. From this information, deprivation quintile (DQ) was derived using the Scottish Index of Multiple Deprivation (SIMD) database and place of death compared between DQs and analysed statistically.

RESULTS

Across all DQs, patients known to SPC services were more likely to die in the hospice than at home or in hospital. There was, however, a small but statistically significant difference in the ratio of hospital deaths compared to hospice deaths between the DQs, with higher death rates in hospital for the most deprived compared to the least deprived and higher death rates in the hospice for the least deprived compared to the most deprived.

CONCLUSIONS

This study suggests that even after referral to specialist palliative care services variation in place of death by deprivation persists. Greater deprivation is associated with increased likelihood of dying in hospital and decreased likelihood of dying in a hospice, although no difference was noted for home deaths.

The changing demographics of inpatient hospice death: Population-based cross-sectional study in England, 1993-2012

BACKGROUND

Studies in the United Kingdom and elsewhere have suggested inequality of hospice provision with respect to factors such as age, diagnosis and socio-economic position. How this has changed over time is unknown.

AIM

To describe the factors associated with inpatient hospice death in England and examine how these have changed over time.

DESIGN

Population-based study. Multivariable Poisson regression compared 1998-2002, 2003-2007 and 2008-2012, with 1993-1997. Explanatory variables included individual factors (age, gender, marital status, underlying cause of death) and area-based measures of deprivation.

SETTING

Adults aged 25 years and over who died in inpatient hospice units in England between 1993 and 2002 (n = 446,615).

RESULTS

The annual number of hospice deaths increased from 17,440 in 1993 to 26,032 in 2012, accounting for 3.4% of all deaths in 1993 and 6.0% in 2012. A total of 50.6% of hospice decedents were men; the mean age was 69.9 (standard deviation: 12.4) years. The likelihood of hospice decedents being in the oldest age group (>85 years) increased over time (proportion ratio: 1.43, 95% confidence interval: 1.39 to 1.48 for 2008-2012 compared to 1993-1997). Just 5.2% of all hospice decedents had non-cancer diagnoses, though the likelihood of non-cancer conditions increased over time (proportion ratio: 1.41, 95% confidence interval: 1.37 to 1.46 for 2008-2012 compared to 1993-1997). The likelihood of hospice decedents being resident in the least deprived quintile increased over time (proportion ratio: 1.25, 95% confidence interval: 1.22 to 1.29 for 2008-2012 compared to 1993-1997).

CONCLUSION

The increase in non-cancer conditions among hospice decedents is encouraging although absolute numbers remain very small. Deprivation trends are concerning and require further exploration.

The importance of identifying preferred place of death

Objectives

The majority of people would prefer to die at home and the stated intentions of both statutory and voluntary healthcare providers aim to support this. This service evaluation compared the preferred and actual place of death of patients known to a specialist community palliative care service.

Design

All deaths of patients (n=2176) known to the specialist palliative care service over a 5-year period were examined through service evaluation to compare the actual place of death with the preferred place of death previously identified by the patient. Triggers for admission were established when the patients did not achieve this preference.

Results

Between 2009 and 2013, 73% of patients who expressed a choice about their preferred place of death and 69.3% who wanted to die at home were able to achieve their preferences. During the course of their illness, 9.5% of patients changed their preference for place of death. 30% of patients either refused to discuss or no preference was elicited for place of death.

Conclusions

Direct enquiry and identification of preferences for end-of-life care is associated with patients achieving their preference for place of death. Patients whose preferred place of death was unknown were more likely to be admitted to hospital for end-of-life care.

Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada

Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Family caregivers voice their needs: A photovoice study

Objective:

Caregivers often are unprepared for their role yet serve as the frontline in the provision of palliative care services. The aim of our study was to explore family caregivers' experiences from their perspective as they cared for dying relatives.

Method:

Using the Photovoice methodology, ten unpaid family caregivers took photographs depicting issues they experienced as informal caregivers of an ill family member who had less than a year to live. Each participant met with the first author individually four to six times and explained their role as caregiver through photographs and stories.

Results:

The results were clustered into seven themes: physical demands, emotional/spiritual stress, preparing for the future, securing help, medication management, navigating the agencies, and relationships.

Significance of results:

Caregivers perform a variety of tasks, often under stress. This study highlights the main areas where problems lie and the areas that palliative care health professionals need to be aware of so they can assist and educate caregivers, with the goal of finding solutions to the burdens of care. The themes were found to be intertwined, showing the complexity of the caregiving role.

The troubles of telling: managing communication about the end of life

Communication about palliative care represents one of the most difficult interpersonal aspects of medicine. Delivering the "terminal" diagnosis has traditionally been the focus of research, yet transitions to specialist palliative care are equally critical clinical moments. Here we focus on 20 medical specialists' strategies for engaging patients around referral to specialist palliative care. Our aim was to develop an understanding of the logics that underpin their communication strategies when negotiating this transition. We draw on qualitative interviews to explore their accounts of deciding whether and when to engage in referral discussions; the role of uncertainty and the need for hope in shaping communication; and their perceptions of how patient biographies might shape their approaches to, and communication about, the end of life. On the basis of our analysis, we argue that communication is embedded in social relations of hope, justice, and uncertainty, as well as being shaped by patient biographies.

The association between in-patient death, utilization of hospital resources and availability of palliative home care for cancer patients

BACKGROUND

The impact of palliative home care programs on in-patient admissions and deaths has not been appropriately established.

AIM

The main objectives of this study have been to evaluate the frequency of in-patient hospital deaths and the use of hospital resources among cancer patients in two areas of the Madrid Region, as well as to assess differences between one area with and one without a palliative home care team (PHCT) in those variables.

DESIGN AND SETTING

We conducted a population-based study comparing two adjacent metropolitan areas of approximately 200,000 inhabitants each in the Madrid Region, Spain, measuring in-patient deaths, emergency room admissions and in-patient days among cancer patients who died in 2005. Only one of the two areas had a fully established PHCT.

RESULTS

524/549 cancer patients (95%) had an identified place of death: 74% died in hospital, 17% at home, 6% in an in-patient hospice and 3% in a nursing home. The frequency of hospital deaths was significantly lower among patients of the PHCT area (61% versus 77%, p < 0.001), as well as the number of patients using emergency and in-patient services (68% versus 79%, p = 0.004, and 66 versus 76%, p = 0.012, respectively). After adjusting for other factors, the risk of hospital death was lower among patients older than 80 (OR, 95% CI, 0.3, 0.1-0.5), higher among patients with hematological malignancies (OR 6.1, 2.0-18.9) and lower among patients of the PHCT area (OR 0.4, 0.2-0.6).

CONCLUSIONS

Our findings suggest that a PHCT is associated with reduced in-patient deaths and overall hospitalization over the last two months of life.

Perceived risks around choice and decision making at end-of-life: a literature review

BACKGROUND

the World Health Organization identifies meeting patient choice for care as central to effective palliative care delivery. Little is known about how choice, which implies an objective balancing of options and risks, is understood and enacted through decision making at end-of-life.

AIM

to explore how perceptions of 'risk' may inform decision-making processes at end-of-life.

DESIGN

an integrative literature review was conducted between January and February 2010. Papers were reviewed using Hawker et al.'s criteria and evaluated according to clarity of methods, analysis and evidence of ethical consideration. All literature was retained as background data, but given the significant international heterogeneity the final analysis specifically focused on the UK context.

DATA SOURCE

the databases Medline, PsycINFO, Assia, British Nursing Index, High Wire Press and CINAHL were explored using the search terms decision*, risk, anxiety, hospice and palliative care, end-of-life care and publication date of 1998-2010.

RESULTS

thematic analysis of 25 papers suggests that decision making at end-of-life is multifactorial, involving a balancing of risks related to caregiver support; service provider resources; health inequalities and access; challenges to information giving; and perceptions of self-identity. Overall there is a dissonance in understandings of choice and decision making between service providers and service users.

CONCLUSION

the concept of risk acknowledges the factors that shape and constrain end-of-life choices. Recognition of perceived risks as a central factor in decision making would be of value in acknowledging and supporting meaningful decision making processes for patients with palliative care needs and their families.

Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium

BACKGROUND

Educational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use.

OBJECTIVES

To examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use.

RESEARCH DESIGN

A retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use.

SUBJECTS

A Belgian nationwide representative sample of people who died not suddenly in 2005-2007.

RESULTS

In comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life.

CONCLUSIONS

Less well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.

End-of-life care in the oldest old

Objective:

The aim of this study was to describe the last year of life of a sample of the oldest old, focusing on care trajectories, health, social networks, and function in daily life activities.

Method:

Data originated from the NONA study, a longitudinal study of 193 individuals among the oldest old living in a Swedish municipality. During this longitudinal study, 109 participants died. Approximately one month after their death, a relative was asked to participate in a telephone interview concerning their relative's last year of life. One hundred two relatives agreed to participate.

Results:

Most of the elderly in this sample of the oldest old (74.5%) died at an institution and the relatives were mostly satisfied with the end-of-life care. The oldest old relatives estimated that the health steadily declined during the last year of life, and that there was a decline in performing of daily life activities. They also estimated that those dying in institutions had fewer social contacts than those dying in a hospital or at home.

Significance of results:

Care at end of life for the oldest old is challenged by problems with progressive declines in ability to perform activities of daily living and health. The findings also highlight the need to support social networks at eldercare institutions.

Part 2: Home-based family caregiving at the end of life: a comprehensive review of published qualitative research (1998-2008)

Family caregivers are crucial for supporting home death. We reviewed published qualitative research on home-based family caregiving at end of life (1998-2008), synthesizing key findings and identifying gaps where additional research is needed. Multiple databases were searched and abstracts reviewed for a focus on family caregiving and palliative care; full articles were reviewed to extract data for this review. In total, 105 articles were included. Findings are presented in the following areas: the caregiving experience and contextual features; supporting family caregivers at end of life; caregiving roles and decision-making; and rewards, meaning and coping. We noted a lack of definitional clarity; a reliance on interview methods and descriptive, thematic analyses, and a relative lack of diversity of patient conditions. Research needs are identified in several areas, including the bereavement experience, caregiver ambivalence, access to services, caregiver meaning-making, and relational and contextual influences on family caregiving at end of life.

Vulnerability and access to care for South Asian Sikh and Muslim patients with life limiting illness in Scotland: prospective longitudinal qualitative study

OBJECTIVES

To examine the care experiences of South Asian Sikh and Muslim patients in Scotland with life limiting illness and their families and to understand the reasons for any difficulties with access to services and how these might be overcome.

DESIGN

Prospective, longitudinal, qualitative design using in-depth interviews.

SETTING

Central Scotland.

PARTICIPANTS

25 purposively selected South Asian Sikh and Muslim patients, 18 family carers, and 20 key health professionals.

RESULTS

92 interviews took place. Most services struggled to deliver responsive, culturally appropriate care. Barriers to accessing effective end of life care included resource constrained services; institutional and, occasionally, personal racial and religious discrimination; limited awareness and understanding among South Asian people of the role of hospices; and difficulty discussing death. The most vulnerable patients, including recent migrants and those with poor English language skills, with no family advocate, and dying of non-malignant diseases were at particularly high risk of inadequate care.

CONCLUSIONS

Despite a robust Scottish diversity policy, services for South Asian Sikh and Muslim patients with life limiting illness were wanting in many key areas. Active case management of the most vulnerable patients and carers, and "real time" support, from where professionals can obtain advice specific to an individual patient and family, are the approaches most likely to instigate noticeable improvements in access to high quality end of life care. Improving access to palliative care for all, particularly those with non-malignant illnesses, as well as focusing on the specific needs of ethnic minority groups, is required.

Knowledge and information needs of informal caregivers in palliative care: a qualitative systematic review

OBJECTIVES

To review current understanding of the knowledge and information needs of informal caregivers in palliative settings.

DATA SOURCES

Seven electronic databases were searched for the period January 1994--November 2006: Medline, CINAHL, PsychINFO, Embase, Ovid, Zetoc and Pubmed using a meta-search engine (Metalib). Key journals and reference lists of selected papers were hand searched.

REVIEW METHODS

Included studies were peer-reviewed journal articles presenting original research. Given a variety of approaches to palliative care research, a validated systematic review methodology for assessing disparate evidence was used in order to assign scores to different aspects of each study (introduction and aims, method and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalizability, implications and usefulness). Analysis was assisted by abstraction of the key details of each study into a table.

RESULTS

Thirty-four studies were included from eight different countries. The evidence was strongest in relation to pain management, where inadequacies in caregiver knowledge and the importance of education were emphasized. The significance of effective communication and information sharing between patient, caregiver and service provider was also emphasized. The evidence for other caregiver knowledge and information needs, for example in relation to welfare and social support, was weaker. There was limited literature on non-cancer conditions and the care-giving information needs of black and minority ethnic populations. Overall, the evidence base was predominantly descriptive and dominated by small-scale studies, limiting generalizability.

CONCLUSIONS

As palliative care shifts into patients' homes, a more rigorously researched evidence base devoted to understanding caregivers knowledge and information needs is required. Research design needs to move beyond the current focus on dyads to incorporate the complex, three-way interactions between patients, service providers and caregivers in end-of-life care settings.

Palliative care provision for people with intellectual disabilities: interviews with specialist palliative care professionals in London

Growing numbers of people with intellectual disabilities (ID) are in need of palliative care, but there is inequity of access to palliative care services for this group. This study investigates the issues and difficulties arising for palliative care staff in providing care for people with ID. Semi-structured interviews were conducted with 32 palliative care professionals in London. Factors affecting palliative care provision for people with ID included social issues (home situation and family issues), emotional and cognitive issues (fear, patient understanding, communication, cooperation and capacity to consent), problems with assessment, and the impact on staff and other patients. An underlying theme was the need to take more time and to build trust. Despite the challenges, many palliative care staff managed the care of people with ID well. The importance of collaboration with carers and ID services is highlighted. Further studies are needed to investigate how widespread the problems are.

Demographic factors and awareness of palliative care and related services

BACKGROUND

Palliative care is not accessed by all those who can benefit from it. Survey aim: To explore awareness of palliative care and related services among UK oncology out-patients, and to analyse the relationship between demographic characteristics and knowledge.

DESIGN

Cross-sectional interview-based survey. Analysis comprised univariate and multiple logistic regression.

PARTICIPANTS AND SETTINGS

Oncology out-patients receiving curative treatments at two district general hospitals in north-west London between December 2004 and April 2005.

RESULTS

A total of 252 (94%) eligible clinic patients were interviewed. Only 47 (18.7%) patients recognised the term 'palliative care', but 135 (67.8%) understood the role of the hospice, and 164 (66.7%) understood the role of Macmillan nurses. Age-adjusted multiple logistic regression showed that recognizing the term 'palliative care' was more likely among the most socially and materially affluent patients than those who were the poorest (OR: 8.4, CI: 2.17-31.01, p =0.002). Understanding the role of Macmillan nurses was also more likely among the most socially and materially affluent patients compared with the poorest patients (OR: 7.0, CI: 2.41-18.52, p <0.0001), and was independently less likely among patients from black and minority ethnic groups than those who were classified as being white British (OR=0.5, CI:0.25-0.96, p =0.04).

CONCLUSIONS

Awareness of palliative care and related services was low among black and minority ethnic groups, and the least affluent.