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Boven C, Dillen L, Van Humbeeck L, Van Den Block L, Piers R, Van Den Noortgate N. Relatives' needs in terms of bereavement care throughout euthanasia processes: A qualitative study. J Clin Nurs 2024; 33:3259-3272. [PMID: 38661114 DOI: 10.1111/jocn.17185] [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: 04/13/2023] [Revised: 03/27/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
AIM To explore relatives' needs in terms of bereavement care during euthanasia processes, how healthcare providers respond to these needs, and the degree of commonality between relatives' and healthcare providers' reports. DESIGN A phenomenological design was employed, utilising reflexive thematic analysis to examine interviews conducted with relatives (N = 19) and healthcare providers (N = 47). RESULTS Relatives' needs throughout euthanasia processes are presented in five main themes and several subthemes, with similar findings between both sets of participants. Although relatives infrequently communicated their needs explicitly to healthcare providers, they appreciated it when staff proactively met their needs. Healthcare providers aimed to assist with the relatives' grief process by tending to their specific needs. However, aftercare was not consistently offered, but relatives did not have high expectations for professional follow-up care. CONCLUSION Our research offers important directions for healthcare professionals, empowering them to provide needs-based bereavement care during euthanasia processes. Moreover, it emphasises the importance of recognising the unique needs of relatives and proactively addressing them in the period before the loss to positively contribute to relatives' grief process. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Insights into relatives' needs in the context of euthanasia. Good practices on how healthcare providers can attend to relatives' needs before, during and after the loss IMPACT: Current literature and guidelines on needs-based bereavement care in the context of euthanasia and, more generally, assisted dying, are limited. These findings provide concrete directions for practice in supporting (nearly) bereaved relatives in the context of euthanasia, potentially mitigating adverse health outcomes. REPORTING METHOD Standards for Reporting Qualitative Research (SRQR checklist). PATIENT OR PUBLIC CONTRIBUTION Relatives of deceased cancer patients were involved in the conduct of the study.
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Affiliation(s)
- Charlotte Boven
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Let Dillen
- Department of Geriatric Medicine and Palliative Care Unit, Ghent University Hospital, Ghent, Belgium
| | | | - Lieve Van Den Block
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels Health Campus, Brussels, Belgium
- End-of-Life Care Research Group, Ghent University, Campus Ghent University Hospital, Ghent, Belgium
- Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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Lichtenthal WG, Roberts KE, Donovan LA, Breen LJ, Aoun SM, Connor SR, Rosa WE. Investing in bereavement care as a public health priority. Lancet Public Health 2024; 9:e270-e274. [PMID: 38492580 PMCID: PMC11110717 DOI: 10.1016/s2468-2667(24)00030-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/18/2024]
Abstract
Morbidity and mortality associated with bereavement is an important public health issue, yet economic and resource investments to effectively implement and sustain integrated bereavement services are sorely lacking at national and global levels. Although bereavement support is a component of palliative care provision, continuity of care for bereaved individuals is often not standard practice in palliative and end-of-life contexts. In addition to potentially provoking feelings of abandonment, failure to extend family-centred care after a patient's death can leave bereaved families without access to crucial psychosocial support and at risk for illnesses that exacerbate the already substantial public health toll of interpersonal loss. The effect of inadequate bereavement care disproportionately disadvantages vulnerable groups, including those living in resource-constrained settings. We build on available evidence and previous recommendations to propose a model for transitional care, firmly establishing bereavement care services within health-care institutions, while respecting their finite resources and the need to ultimately transition grieving families to supports within their communities. Key to the transitional bereavement care model is the bolstering of community-based supports through development of compassionate communities and upskilling of professional services for those with more substantial bereavement support needs. To achieve this goal, interprofessional health workers, institutions, and systems must shift bereavement care from an afterthought to a public health priority.
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Affiliation(s)
- Wendy G Lichtenthal
- Center for the Advancement of Bereavement Care, Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, FL, USA; Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Kailey E Roberts
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY, USA
| | - Leigh A Donovan
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Lauren J Breen
- Curtin School of Population Health and Curtin enAble Institute, Curtin University, Perth, WA, Australia
| | - Samar M Aoun
- Medical School, University of Western Australia, Perth, WA, Australia; Perron Institute for Neurological and Translational Science, Perth, WA, Australia; School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | | | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cullen I, Bailes M, Shropshire P, Perry S, Karlekar M. Connecting Families to Bereavement Resources: A Hospital-Based, Bereavement Follow-Up Pilot During First-Wave COVID-19. J Palliat Med 2024; 27:532-536. [PMID: 38346311 DOI: 10.1089/jpm.2023.0375] [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] [Indexed: 04/06/2024] Open
Abstract
Background: Hospitals often lack bereavement programs. Bereaved families often navigate grief support on their own. This problem was complicated by the early COVID-19 pandemic. Objective: Describe a cost neutral pilot to support next of kin (NOK) of deceased patients from our communicable disease response unit (CDRU) and palliative care unit (PCU). Design: Ad hoc pilot leveraging chaplains and a social worker (SW) to call NOK for grief support using a templated guide, referring interested NOK to bereavement support agencies. Setting/Subjects: NOK of patients who died in the CDRU and PCU at a metropolitan, quaternary care, hospital over five months. Results: One hundred eighty-six patients died. Eighty-one NOK were called, 51 calls were considered complete. Fourteen NOK accepted a referral for bereavement support. Conclusions: This cost neutral pilot successfully connected 81 NOK with either a pilot chaplain or SW for bereavement support. Fourteen NOK accepted referral for a community bereavement resource.
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Affiliation(s)
- Ian Cullen
- Vanderbilt University Medical Center, Department of Spiritual and Pastoral Care, Nashville, Tennessee, USA
| | - Melinda Bailes
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patricia Shropshire
- Vanderbilt University Medical Center, Department of Spiritual and Pastoral Care, Nashville, Tennessee, USA
| | - Sherry Perry
- Vanderbilt University Medical Center, Department of Spiritual and Pastoral Care, Nashville, Tennessee, USA
| | - Mohana Karlekar
- Vanderbilt University Medical Center, Division of Internal Medicine and Public Health, Nashville, Tennessee, USA
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Bereavement care provision and its associated factors among nurses in cancer care settings: a cross-sectional study. Support Care Cancer 2022; 30:7625-7633. [PMID: 35676344 DOI: 10.1007/s00520-022-07180-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/25/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The goals of this study were to (1) investigate bereavement care provision in practical settings, (2) examine the difference in care by nurses' affiliation (general hospital, hospice, or homecare setting), and (3) identify institutional and personal barriers associated with bereavement care provision. METHODS A cross-sectional survey was conducted using an online questionnaire. Nurses (n = 309) who had an experience of cancer patient care before death at least once in a previous year were included in the analysis. Kruskal-Wallis test and Mann-Whitney test were conducted to compare bereavement care provision by nurses' affiliation, and hierarchical logistic regression analysis was conducted to investigate the correlation between bereavement care provision and its associated factors. RESULTS Less than 30% of nurses reported providing bereavement care in structured settings such as home visits, counseling at a hospital, or phone calls. The differences in bereavement care provision by nurses' affiliation were significant, and the nurses working in a hospital were less likely to provide bereavement care than those working in a hospice or homecare setting. Working in a palliative care setting (OR = 2.35, 95%CI 1.09-5.07, p < 0.05) and greater confidence (OR = 2.18, 95%CI 1.07-4.42, p < 0.05) and knowledge regarding bereavement care (OR = 12.46, 95%CI 5.69-27.29, p < 0.001) were significantly associated factors of bereavement care provision. CONCLUSION This study indicated a lack of bereavement care provision, especially in general hospitals. Improving nurses' confidence and knowledge may encourage them to provide bereavement care provision.
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Boven C, Dillen L, Van den Block L, Piers R, Van Den Noortgate N, Van Humbeeck L. In-Hospital Bereavement Services as an Act of Care and a Challenge: An Integrative Review. J Pain Symptom Manage 2022; 63:e295-e316. [PMID: 34695567 DOI: 10.1016/j.jpainsymman.2021.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/13/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT Globally, people most often die within hospitals. As such, healthcare providers in hospitals are frequently confronted with dying persons and their bereaved relatives. OBJECTIVES To provide an overview of the current role hospitals take in providing bereavement care. Furthermore, we want to present an operational definition of bereavement care, the way it is currently implemented, relatives' satisfaction of receiving these services, and finally barriers and facilitators regarding the provision of bereavement care. METHODS An integrative review was conducted by searching four electronic databases, from January 2011 to December 2020, resulting in 47 studies. Different study designs were included and results were reported in accordance with the theoretical framework of Whittemore and Knafl (2005). RESULTS Only four articles defined bereavement care: two as services offered solely post loss and the other two as services offered pre and post loss. Although different bereavement services were delivered the time surrounding the death, the follow-up of bereaved relatives was less routinely offered. Relatives appreciated all bereavement services, which were rather informally and ad-hoc provided to them. Healthcare providers perceived bereavement care as important, but the provision was challenged by numerous factors (such as insufficient education and time). CONCLUSION Current in-hospital bereavement care can be seen as an act of care that is provided ad-hoc, resulting from the good-will of individual staff members. A tiered or stepped approach based on needs is preferred, as it allocates funds towards individuals-at-risk. Effective partnerships between hospitals and the community can be a useful, sustainable and cost-effective strategy.
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Affiliation(s)
- Charlotte Boven
- Department of Geriatric Medicine (C.B., R.P., N.V.D.N., L.V.H.), Ghent University Hospital, Ghent, Belgium.
| | - Let Dillen
- Department of Geriatric Medicine and Palliative Care Unit (L.D.), Ghent University Hospital, Ghent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group (L.V.D.B.), Vrije Universiteit Brussel (VUB) & Ghent University, Brussels Health Campus (Building C), Laarbeeklaan 103, 1090 Brussels, Belgium & Campus Ghent University Hospital (Entrance 42 K3), Ghent, Belgium; Department of Family Medicine and Chronic Care (L.V.D.B.), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ruth Piers
- Department of Geriatric Medicine (C.B., R.P., N.V.D.N., L.V.H.), Ghent University Hospital, Ghent, Belgium
| | - Nele Van Den Noortgate
- Department of Geriatric Medicine (C.B., R.P., N.V.D.N., L.V.H.), Ghent University Hospital, Ghent, Belgium
| | - Liesbeth Van Humbeeck
- Department of Geriatric Medicine (C.B., R.P., N.V.D.N., L.V.H.), Ghent University Hospital, Ghent, Belgium
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Solis RN, Farber NI, Fairman N, Yang NT, Taylor SL, Abouyared M, Bewley AF, Farwell DG, Birkeland AC. Bereavement Practices Among Head and Neck Cancer Surgeons. Laryngoscope 2022; 132:1971-1975. [PMID: 35092314 DOI: 10.1002/lary.30037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/28/2021] [Accepted: 01/15/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Head and neck cancer surgeons frequently interact with dying patients with advanced disease and their families, but little is known about their bereavement practices after a patient's death. The aim of this study is to elucidate the frequency of common bereavement practices, cited barriers to bereavement, and predictive physician factors that lead to an increase in bereavement practices among head and neck cancer surgeons. METHODS A 20-item survey was sent to 827 active surgeons of the American Head and Neck Society. Approval was obtained and the survey was distributed through the American Head and Neck Society. Demographics, frequency of common bereavement practices, empathy, and barriers were assessed. Multiple linear regression was performed to determine physician factors associated with more frequent bereavement follow-up. RESULTS There were 156 respondents (18.9% response rate). Overall, surgeons were more likely to usually/always call (48.5%) or send a letter (42.4%) compared with other practices such as attending funerals (0%), offering family meetings (18.6%), or referring family members to counseling (7.7%). Many barriers were cited as being at least somewhat important: being unaware about a patient's death (67.3%) was the most cited, whereas 51.3% cited a lack of mentorship/training in this area. Scoring higher on empathy questions (P ≤ .001) was associated with more frequent surgeon bereavement follow-up with the family of deceased patients. CONCLUSION There is substantial practice variation among surgeons suggesting a lack of consensus on their roles in bereavement follow-up. Having higher empathy was predictive of higher engagement. LEVEL OF EVIDENCE NA Laryngoscope, 2022.
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Affiliation(s)
- Roberto N Solis
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Nicole I Farber
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Nathan Fairman
- Department of Psychiatry, University of California, Davis, Sacramento, California, U.S.A
| | - Nuen T Yang
- Division of Biostatistics, School of Medicine, University of California, Davis, Sacramento, California, U.S.A
| | - Sandra L Taylor
- Division of Biostatistics, School of Medicine, University of California, Davis, Sacramento, California, U.S.A
| | - Marianne Abouyared
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Arnaud F Bewley
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - D Gregory Farwell
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Andrew C Birkeland
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
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Kim K, Churilov L, Tan CO, Phan T, Geertsema J, Krieser R, Mehra R, Stewart PA, Rachbuch C, Huang A, Weinberg L. Anaesthetists' attitudes towards attending the funerals of their patients: A cross-sectional study among Australian and New Zealand anaesthetists. PLoS One 2020; 15:e0239996. [PMID: 33151958 PMCID: PMC7643987 DOI: 10.1371/journal.pone.0239996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/16/2020] [Indexed: 11/29/2022] Open
Abstract
A patient’s death can pose significant stress on the family and the treating anaesthetist. Anaesthetists’ attitudes about the benefits of and barriers to attending a patient’s funeral are unknown. Therefore, we performed a prospective, cross-sectional study to ascertain the frequency of anaesthetists’ attendance at a patient’s funeral and their perceptions about the benefits and barriers. The primary aim was to investigate the attitudes of anaesthetists towards attending the funeral of a patient. The secondary aims were to examine the perceived benefits of and barriers to attending the funeral and to explore the rate of bonds being formed between anaesthetists, patients and families. Of the 424 anaesthetists who completed the survey (response rate 21.2%), 25 (5.9%) had attended a patient’s funeral. Of the participants, 364 (85.9%) rarely formed special bonds with patients or their families; 233 (55%) believed that forming a special bond would increase the likelihood of their attendance. Showing respect to patients or their families was the most commonly perceived benefit of attending a funeral. Participants found expression of personal grief and caring for the patient at the end-of-life and beyond beneficial to themselves and the family. Fear of their attendance being misinterpreted or perceived as not warranted by the family as well as time restraints were barriers for their attendance. Most anaesthetists had never attended a patient’s funeral. Few anaesthetists form close relationships with patients or their families. Respect, expression of grief and caring beyond life were perceived benefits of attendance. Families misinterpreting the purpose of attendance or not expecting their attendance and time restraints were commonly perceived barriers. Trial registration:ACTRN 12618000503224.
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Affiliation(s)
- Kwangtaek Kim
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine (Austin Health) & Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne Medical School, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Tuong Phan
- Department of Anaesthesia, St Vincent’s Hospital, Fitzroy, Victoria, Australia
| | - Jake Geertsema
- Department of Anaesthesia, The Northern Hospital, Epping, Victoria, Australia
| | - Roni Krieser
- Department of Anaesthesia, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rishi Mehra
- Department of Anaesthesia, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Anthony Stewart
- Department of Anaesthesia, Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Clive Rachbuch
- Department of Anaesthesia, Box Hill Hospital, Box Hill, Victoria, Australia
| | - Andrew Huang
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Victoria, Australia
- * E-mail:
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Ito Y, Obana M, Kawakami D, Murakami N, Sakaguchi Y. The current status of bereavement follow-up in Japanese emergency departments: A cross-sectional nationwide survey. Int Emerg Nurs 2020; 52:100872. [PMID: 32312686 DOI: 10.1016/j.ienj.2020.100872] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/24/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the current status of bereavement follow-up in Japanese emergency departments. METHODS This study employed a cross-sectional design and conducted a nationwide survey of all emergency departments in Japan. Self-reported questionnaires were sent to the nurse leaders of each emergency department. RESULTS Of 289 nurse leaders approached, 145 (50.2%) responded. Only 17.9% emergency departments provided bereavement follow-up strategies, and the most frequent strategy was referral to a specialist for psychological treatment. Most nurse leaders perceived that bereavement follow-up is necessary, and the greatest need of the bereaved as perceived by the nurse leaders was explanation of the patient's death. However, 60% of the nurse leaders perceived bereavement follow-up to be necessary but difficult, and the major challenges in bereavement follow-up were lack of time, knowledge, and skill. CONCLUSION In contemporary Japan, the prevalence of bereavement follow-up strategies offered by emergency departments was low, and although most nurse leaders perceived follow-up as necessary, it could not be provided because of limitations in human resources and staff training.
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Affiliation(s)
- Yoshiyasu Ito
- College of Nursing Art and Science, University of Hyogo, 13-71 Kitaoujicho, Akashi City, Hyogo 673-0021, Japan.
| | - Miyuki Obana
- Department of Nursing, Yokohama Municipal Citizen's Hospital, 56 Okazawacho, Hodogaya-ku, Yokohama City, Kanagawa 240 8555, Japan
| | - Daisuke Kawakami
- Department of Nursing, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara City, Kanagawa 252 0375, Japan
| | - Noriko Murakami
- Department of Psychosomatic Internal Medicine, Japanese Red Cross Kobe Hospital, 1-3-1 Wakinohamakaigandori, Chuou-ku, Kobe City, Hyogo 651 0073, Japan
| | - Yukihiro Sakaguchi
- Graduate School of Human Welfare, Kwansei Gakuin University, 1-155 Uegaharaichibancho, Nishinomiya, Hyogo City 662 8501, Japan
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Ó Coimín D, Prizeman G, Korn B, Donnelly S, Hynes G. Dying in acute hospitals: voices of bereaved relatives. BMC Palliat Care 2019; 18:91. [PMID: 31672137 PMCID: PMC6824032 DOI: 10.1186/s12904-019-0464-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 09/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals. Methods Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate). Results The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support. Conclusions This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative’s priorities for EoLC in acute hospitals and can advance care providers’, policy makers’ and educationalists’ priorities for service improvement.
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Affiliation(s)
- Diarmuid Ó Coimín
- End-of-Life Care, Mater Misericordiae University Hospital, Quality and Patient Safety Directorate, Eccles Street, Dublin 7, Ireland.
| | - Geraldine Prizeman
- Trinity Centre for Practice and Healthcare Innovation, School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Bettina Korn
- End-of-Life Care, Hospice Friendly Hospital Programme, 1st Floor CEO Building, St. James's Hospital, James Street, Dublin 8, Ireland
| | - Sarah Donnelly
- Social Work, School of Social Policy, Social Work and Social Justice, University College, Dublin, Ireland
| | - Geralyn Hynes
- Palliative Care, School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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Kim K, Churilov L, Huang A, Weinberg L. Bereavement practices employed by hospitals and medical practitioners toward attending funeral of patients: A systematic review. Medicine (Baltimore) 2019; 98:e16692. [PMID: 31490361 PMCID: PMC6739025 DOI: 10.1097/md.0000000000016692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To ascertain bereavement practices offered by hospitals and medical practitioners (MPs), factors that influence the likelihood of MPs' involvement in funeral attendance, the benefits and barriers to attendance to a patient's funeral as perceived by MPs and the rate of attendance to patients' funeral by MPs. DESIGN MEDLINE (Ovid), Embase, PubMed, and Google Scholar were searched with a systematic search structure for randomized controlled trials, comparative observational studies, case series, cross-sectional studies, editorials, and letters. The search was limited to English only. The study was registered with Prospero (Registration Number: CRD42018095368). RESULTS A total of 381 articles were identified with 46 articles meeting the inclusion criteria. Of the 46, 16 were editorials and 12 were letters. Eighteen were cross-sectional studies conducted in the United States, Canada, Australia, Israel, and Ireland. Year of publication ranged from 1990 to 2017. Of these, 12 were quantitative, 3 were qualitative, and 3 were mixed-method studies. Two of the cross-sectional studies involved family members of deceased patients while others involved MPs. Bereavement practices offered by hospitals included memorial services, letters, and services provided by bereavement coordinators. Bereavement practices employed by MPs included answering or making phone calls, attending family meetings, and sending condolence letters. MPs' attendance at a patient's funeral was influenced by MPs' gender, age years of experience the medical specialty. Perceived benefits of MPs' attendance at a patient's funeral included providing support to the family, extending the professional relationship, illustrating respect to the patient and the family, resolving guilt and personal growth. Barriers to the attendance included a lack of time, blurring of professional boundaries, personal discomfort with death, emotional arousal, and discouragement by colleagues. General practice had an attendance rate of 71%. Attendance rates for palliative care, oncology, and psychiatrists ranged from 63% to 81%, 7.1% to 67%, and 15% to 67%, respectively. Intensivists had an attendance rate of 22%. CONCLUSION Several bereavement practices are provided by hospitals and MPs. Funeral attendance is an uncommon bereavement practice. MPs' attitudes toward attending a patient's funeral are understudied in many specialties. Patient factors that influence MPs' participation in bereavement practices are poorly understood.
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Affiliation(s)
| | - Leonid Churilov
- Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Heidelberg, Australia
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How to Say Goodbye: Simple Lessons for the Cardiovascular Physician When Faced With Patient Death. J Am Coll Cardiol 2019; 74:154-156. [PMID: 31272538 DOI: 10.1016/j.jacc.2019.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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My Condolences: Making Bereavement Contact Part of Our Standard Operating Procedures. J Palliat Med 2018; 21:1058-1059. [DOI: 10.1089/jpm.2018.0308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Makarem M, Mohammed S, Swami N, Pope A, Kevork N, Krzyzanowska M, Rodin G, Hannon B, Zimmermann C. Experiences and Expectations of Bereavement Contact among Caregivers of Patients with Advanced Cancer. J Palliat Med 2018; 21:1137-1144. [DOI: 10.1089/jpm.2017.0530] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Maisam Makarem
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Shan Mohammed
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Nanor Kevork
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Monika Krzyzanowska
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Breffni Hannon
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Kentish-Barnes N, Chevret S, Champigneulle B, Thirion M, Souppart V, Gilbert M, Lesieur O, Renault A, Garrouste-Orgeas M, Argaud L, Venot M, Demoule A, Guisset O, Vinatier I, Troché G, Massot J, Jaber S, Bornstain C, Gaday V, Robert R, Rigaud JP, Cinotti R, Adda M, Thomas F, Calvet L, Galon M, Cohen-Solal Z, Cariou A, Azoulay E. Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial. Intensive Care Med 2017; 43:473-484. [DOI: 10.1007/s00134-016-4669-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 12/27/2016] [Indexed: 10/20/2022]
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Zambrano SC, Chur-Hansen A, Crawford GB. Attending patient funerals: Practices and attitudes of Australian medical practitioners. DEATH STUDIES 2017; 41:78-86. [PMID: 27611349 DOI: 10.1080/07481187.2016.1214631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The appropriateness of attending a patient's funeral is a medical dilemma. This article focuses on 437 doctors who participated in an online survey. Seventy-one percent of general practitioners, 67% of oncologists, 67% of psychiatrists, 63% of palliative medicine specialists, 52% of surgeons, and 22% of intensive care specialists had attended patient funerals. Significant differences in demographics and between specialties were identified in terms of barriers and benefits associated with attendance. Although attendance is a personal decision, there is a need for open discussions in medical education and professional development concerning death and the role of doctors after a patient dies.
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Affiliation(s)
- Sofía C Zambrano
- a School of Psychology , The University of Adelaide , Adelaide , Australia
| | - Anna Chur-Hansen
- a School of Psychology , The University of Adelaide , Adelaide , Australia
| | - Gregory B Crawford
- b School of Medicine , The University of Adelaide , Adelaide , Australia
- c Northern Adelaide Palliative Service , Northern Adelaide Local Health Network, Adelaide , Australia
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Jensen J, Weng C, Spraker-Perlman HL. A Provider-Based Survey To Assess Bereavement Care Knowledge, Attitudes, and Practices in Pediatric Oncologists. J Palliat Med 2017; 20:266-272. [PMID: 28072917 DOI: 10.1089/jpm.2015.0430] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Bereavement support is a core tenet of palliative care that may prove difficult for clinicians as it is time-consuming, emotionally charged, and not emphasized in pediatrics training. This project is intended to describe the opinions, knowledge, and practice of bereavement care among pediatric oncologists to identify gaps in clinical care. PROCEDURES An internet-based survey instrument was pilot tested, refined, and distributed to pediatric oncologists in the United States. Statistical analysis was performed using SAS 9.2. RESULTS Electronic surveys were distributed to 2,061 pediatric oncologists and 522 surveys (25%) were fully completed. Participants were asked how likely they are to engage in particular bereavement activities (phone calls, condolence cards, memorial services, family meetings, or referrals for counseling) following the death of a pediatric cancer patient. Eighty-two percent of participants, at least, sometimes engage in at least one of these activities. Being female, an attending physician, and increased time in clinical practice were predictive of active participation in bereavement care. Nearly all participants (96%) believe that bereavement care is part of good clinical care, while 8% indicate that bereavement support is not their responsibility. Lack of time and resources were the biggest barriers to providing bereavement support. CONCLUSIONS The majority of pediatric oncologists engage in clinical practices to support bereaved families. Lack of time and physical resources pose significant barriers to clinician's efforts. Additional supports should be explored to increase pediatric oncology physician uptake of bereavement care practices.
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Affiliation(s)
- Jasmin Jensen
- 1 Division of Pediatric Hematology-Oncology, Kapiolani Medical Center for Women and Children , Honolulu, Hawaii
| | - Cindy Weng
- 2 Study Design and Biostatistics Center, School of Medicine, University of Utah , Salt Lake City, Utah
| | - Holly L Spraker-Perlman
- 3 Division of Pediatric Hematology-Oncology, University of Utah , Primary Children's Hospital, Salt Lake City, Utah
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Granot T, Gordon N, Perry S, Rizel S, Stemmer SM. Factors Affecting Communication Patterns between Oncology Staff and Family Members of Deceased Patients: A Cross-Sectional Study. PLoS One 2016; 11:e0162813. [PMID: 27683075 PMCID: PMC5040255 DOI: 10.1371/journal.pone.0162813] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/29/2016] [Indexed: 11/28/2022] Open
Abstract
Objective Perceptions of the role of oncology medical staff in supporting bereaved families have evolved with the transition to interdisciplinary cancer care. We investigated the interactions between oncology professionals and bereaved families. Methods This cross-sectional study involved all oncology medical staff at the Davidoff Center. Participants were given a questionnaire relating to bereavement follow-up. Responses were measured using a 5-point Likert scale. Results Of 155 staff members, 107 filled questionnaires with <20% missing data and were included in the analysis (α = 0.799; corrected, α = 0.821). Respondents included physicians (35%), nurses (46%), social workers (7%), psychologists (4%), or unspecified (8%); 85% were Jewish, and 60% had ≥10 years of oncology experience. Most respondents thought that contacting bereaved families was important (73%), and that it provided closure for staff (79%); 41% indicated that they contacted >50% of the families of their deceased patients. Contacting bereaved families was considered the responsibility of the physicians (90%), nurses (84%), or social workers (89%). The main barriers to contacting bereaved families were emotional overload (68%) and lack of time (63%); 60% indicated a need for additional communication tools for bereavement follow-up. In a multivariate analysis, profession (physician vs. nurse), primary workplace (outpatient setting vs. other), and self-defined religion were significant variables with respect to the perceived importance of contacting bereaved families and to actually contacting them. Other factors (e.g., age, gender) were non-significant. Conclusions Perspectives regarding bereavement actions differ significantly across medical professions, work settings, and self-defined religions. Additional guidance and education regarding bereavement actions is warranted.
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Affiliation(s)
- Tal Granot
- Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Noa Gordon
- Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Shlomit Perry
- Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | | | - Salomon M. Stemmer
- Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- * E-mail:
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Hayward JS, Makinde O, Vasudev NS. Letters of condolence: assessing attitudes and variability in practice amongst oncologists and palliative care doctors in Yorkshire. Ecancermedicalscience 2016; 10:642. [PMID: 27347006 PMCID: PMC4898960 DOI: 10.3332/ecancer.2016.642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Indexed: 11/17/2022] Open
Abstract
Background Following a patient’s death, some doctors routinely write a letter of condolence to the bereaved family. Practice appears to vary widely but this is poorly documented, particularly in the UK setting. We wished to explore the attitudes of oncologists and palliative care consultants towards writing letters of condolence to patient’s families. Methods A sample of oncology and palliative care consultants from across Yorkshire were invited via email to complete an anonymous online survey. The survey aimed to identify current practice regarding condolence letter writing and respondents attitudes towards this. Results A total of 47 (72%) recipients completed the survey, comprised of clinical oncologists (45%), medical oncologists (42%), and palliative care consultants (13%). The majority (87%) reported sending condolence letters, but amongst this group, only 49% indicated they do this ‘often’ or ‘always’. When asked whether they would use a standard template letter, should it be made available, 77% of participants responded negatively. Many later commented that a template with room for flexibility would be better received. The majority (72%) were also not in favour of the introduction of policies to try to unify practices. Conclusions Practices and attitudes towards condolence letter writing are variable. The participants in this study felt strongly about when and how they wished to express condolences. A single unifying policy seems unlikely to be appropriate or feasible.
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Affiliation(s)
| | | | - Naveen S Vasudev
- Leeds Institute of Cancer and Pathology, University of Leeds, LS9 7TF, UK; St James's Institute of Oncology, Leeds, LS9 7TF, UK
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McAdam JL, Erikson A. Bereavement Services Offered in Adult Intensive Care Units in the United States. Am J Crit Care 2016; 25:110-7. [PMID: 26932912 DOI: 10.4037/ajcc2016981] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Losing a loved one in the intensive care unit (ICU) is stressful for family members. Providing bereavement support to them is recommended. However, little is known about the prevalence of bereavement services implemented in adult ICUs. OBJECTIVE To describe current bereavement follow-up services in adult ICUs. METHOD A cross-sectional prospective study design was used. ICU nurse leaders completed a 26-item online survey posted in the American Association of Critical-Care Nurses e-newsletter. The survey contained questions about current practices in bereavement care. Data were collected for 1 month and were analyzed by using descriptive statistics and binary logistic regression. RESULTS A total of 237 ICU nurse leaders responded to the survey. Hospital and ICU types were diverse, with most being community (n = 81, 34.2%) and medical (n = 61, 25.7%). Most respondents reported that their ICUs (n = 148, 62.4%) did not offer bereavement follow-up services, and many barriers were noted. When bereavement follow-up care was offered, it was mainly informal (eg, condolence cards, brochures). Multiple logistic regression indicated that ICUs in hospitals with palliative care were almost 8 times (odds ratio, 7.66) more likely to provide bereavement support than were ICUs in hospitals without palliative care. CONCLUSIONS The study findings provide insight into what type of bereavement evaluation methods are being used, what barriers are present that hinder use of bereavement follow-up services, and potential interventions to overcome those barriers in adult ICUs in the United States.
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Affiliation(s)
- Jennifer L. McAdam
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
| | - Alyssa Erikson
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
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Kentish-Barnes N, Chevret S, Azoulay E. Impact of the condolence letter on the experience of bereaved families after a death in intensive care: study protocol for a randomized controlled trial. Trials 2016; 17:102. [PMID: 26897630 PMCID: PMC4761130 DOI: 10.1186/s13063-016-1212-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As intensive care mortality is high, end of life is a subject of major concern for intensivists. In this context, relatives are particularly vulnerable and prone to post-ICU syndrome, in the form of high levels of anxiety, depression, post-traumatic stress, and complicated grief. Grieving families suffer from a feeling of abandonment and evoke the need to get back in touch with the team to ask questions and remove doubts, but very few actually do. Aiding families during the grieving process is an important aspect of palliative care. A condolence letter represents an opportunity to recognize the pain of the family member and the strong tie that linked the family member to the ICU team, and to offer additional information if necessary. The goal of the study is to measure the impact of the condolence letter on the experience of bereaved families after a death in the ICU. Our hypothesis is that a post-death follow-up in the form of a condolence letter sent by the ICU physician who was in charge of the patient may help to reduce the risks of presenting symptoms of anxiety/depression, post-traumatic stress, and complicated grief. METHODS/DESIGN This is a randomized, controlled, multicenter study. Research will compare two groups of bereaved family members: one group that does not receive a condolence letter (control) and one group that receives a condolence letter 15 days after the death (intervention). Each of the 22 participating centers will include 12 relatives. Participating relatives will be followed up by phone with a call at 1 month and one at 6 months to complete questionnaires, permitting evaluation of post-ICU burden. The main outcome is anxiety and depression measured at 1 month. Other outcomes include evaluation of quality of dying and death, post-traumatic stress, and complicated grief. DISCUSSION This study will allow us to assess if sending a condolence letter can reduce the risks of presenting symptoms of anxiety and depression, complicated grief, and symptoms of post-traumatic stress disorder after the death of a loved one in the ICU. TRIAL REGISTRATION CLINICAL TRIALS REGISTRATION NUMBER Clinicaltrials.gov NCT02325297 (23 December 2014).
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Affiliation(s)
- Nancy Kentish-Barnes
- Saint-Louis hospital, Medical Intensive Care Unit - Famirea group, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.
| | - Sylvie Chevret
- Saint Louis Hospital, Biostatistics department, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.
- Biostatistics and Clinical Epidemiology, UMR 1153, INSERM, Paris Diderot Sorbonne University, Paris, France.
| | - Elie Azoulay
- Saint-Louis hospital, Medical Intensive Care Unit - Famirea group, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.
- Saint Louis Hospital, Biostatistics department, AP-HP, 1 avenue Claude Vellefaux, 75010, Paris, France.
- Biostatistics and Clinical Epidemiology, UMR 1153, INSERM, Paris Diderot Sorbonne University, Paris, France.
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Merel SE, Stafford MM, White AA, Fligner CL, Amory JK, Hagman MM. Providers' Beliefs about Expressing Condolences to the Family of a Deceased Patient: A Qualitative and Quantitative Analysis. J Palliat Med 2015; 18:217-24. [PMID: 25493629 DOI: 10.1089/jpm.2014.0217] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Susan E. Merel
- University of Washington Medical Center, Seattle, Washington
| | | | - Andrew A. White
- University of Washington Medical Center, Seattle, Washington
| | | | - John K. Amory
- University of Washington Medical Center, Seattle, Washington
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Karlekar M, Collier B, Parish A, Olson L, Elasy T. Utilization and determinants of palliative care in the trauma intensive care unit: results of a national survey. Palliat Med 2014; 28:1062-8. [PMID: 24827834 DOI: 10.1177/0269216314534514] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a paucity of data evaluating utilization of palliative care in trauma intensive care units. AIM We sought to determine current indications and determinants of palliative care consultation in the trauma intensive care units. DESIGN Using a cross-sectional assessment, we surveyed trauma surgeons to understand indications, benefits, and barriers trauma surgeons perceive when consulting palliative care. SETTING/PARTICIPANTS A total of 1232 surveys were emailed to all members of the Eastern Association for the Surgery of Trauma. RESULTS A total of 362 providers responded (29% response rate). Majority of respondents were male (n = 287, 80.2%) and practiced in Level 1 (n = 278, 77.7%) trauma centers. Most common indicators for referral to palliative care were expected survival 1 week to 1 month, multisystem organ dysfunction >3 weeks, minimal neurologic responsiveness >1 week, and referral to hospice. In post hoc analysis, there was a significant difference in frequency of utilization of palliative care when respondents had access to board-certified palliative care physicians (χ(2) = 56.4, p < 0.001). Although half of the respondents (n = 199, 55.6%) reported palliative care consults beneficial all or most of the time, nearly still half (n = 174, 48.6%) felt palliative care was underutilized. Most frequent barriers to consultation included resistance from families (n = 144, 40.2%), concerns that physicians were "giving up" (n = 109, 30.4%), and miscommunication of prognosis (n = 98, 27.4%) or diagnosis (n = 58, 16.2%) by the palliative care physician. CONCLUSION Although a plurality of trauma surgeons reported palliative care beneficial, those surveyed indicate that palliative care is underutilized. Barriers identified provide important opportunities to further appropriate utilization of palliative care services.
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Affiliation(s)
| | - Bryan Collier
- Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Abby Parish
- School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Lori Olson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Tom Elasy
- Vanderbilt University, Nashville, TN, USA
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