Interprofessional working in hospice day care and the patients’ experience of the service

Explaining how and why social support groups in hospice day services benefit palliative care patients, for whom, and in what circumstances

Background

Palliative care aims to provide holistic support for people with life-limiting illness, responding to psychological, social and spiritual needs, as well as to clinical and physical. In the United Kingdom, hospice day services (including day care, group interventions, group activities, and social events for palliative care outpatients) aim to provide opportunities for patients to gain social support, which is thought to improve their quality of life.

Objectives

This research explored social support within hospice day services, to explain in detail how and why social support obtained within a hospice day service could be beneficial to palliative care patients.

Design

Qualitative research using observations of hospice day services and interviews with service providers.

Methods

Data collection involved nineteen interviews with hospice service providers (n = 19) and researcher observations of hospice day services. The findings detail how patient and hospice context interact to produce mechanisms that lead to outcomes beyond the hospice day service.

Results

Practical, clinical and social aspects of the hospice day service are important for patients feeling welcome and safe in the setting. The opportunity to connect with other people and work towards personal goals can boost self-confidence for patients who have lost access to meaningful activity. New friendships between patients encourages reciprocal support and feelings of belonging. It is beneficial to have permission to speak freely about topics deemed inappropriate elsewhere, because honest communication is helpful in accepting and adapting to their circumstances.

Conclusion

Hospice day services facilitate group settings for reciprocal social support. This research proposes an initial programme theory that can be further developed and tested. It explains how and why, in some contexts, social support increases personal and practical resources to cope with illness and death, leading to changes outside of the hospice (to mood, interpersonal interactions and behaviour) that could improve quality of life.

A survey of hospice day services in the United Kingdom & Republic of Ireland : how did hospices offer social support to palliative care patients, pre-pandemic?

INTRODUCTION

Social support is described by patients and other stakeholders to be a valuable component of palliative day care. Less is known about the range of hospice services that have been used in practice that facilitate social support. An online survey aimed to gain an overview of all hospice day services that facilitated social support for adults outside of their own homes.

METHODS

An online survey was distributed via email to people involved in managing hospice day services. Questions were asked on hospice characteristics, including staff and volunteer roles. Respondents were asked to identify services they felt offered social support to patients. Data collection took place between August 2017 and May 2018.

RESULTS

Responses were received from 103 hospices in the UK and ROI (response rate 49.5%). Results provide an overview of hospice day and outpatient services that offer social support to patients. These are: multi-component interventions, activity groups, formal support groups, befriending, and informal social activities. Multi-component interventions, such as palliative day care, were the most commonly reported. Their stated aims tend to focus on clinical aspects, but many survey respondents considered these multicomponent interventions to be the 'most social' service at their hospice. The survey also identified a huge variety of activity groups, as well as formal therapeutic support groups. Informal 'social-only' activities were present, but less common. Over a third of all the services were described as 'drop in'. Most responding hospices did not routinely use patient reported outcome measures in their 'most social' services.

CONCLUSIONS

The survey documents hospice activity in facilitating social support to be diverse and evolving. At the time of data collection, many hospices offered multiple different services by which a patient might obtain social support outside of their own home and in the presence of other patients.

Association between attendance at a specialist palliative care day unit and improvement in patient symptoms and quality of life

BACKGROUND

Specialist palliative day care is an area of palliative care which has a notable scarcity of research. Evidence is needed on the role of palliative day care to improve patients' quality of life and symptom management, while recognising the different patient cohorts that use the service.

AIM

To determine the symptoms and quality of life of the patient cohort that are affected by the completion of a full therapeutic cycle (8 to 9 weeks) at a specialist palliative care day unit (SPCDU).

METHOD

A retrospective cohort study was carried out from January 2016 to December 2017. Patient related outcome measures (PROMs) were collected as part of routine clinical paperwork at admission and discharge, and these were used to determine symptoms and quality of life pre-attendance and on completion of an 8 to 9 week therapeutic cycle at the SPCDU.

RESULTS

Descriptive analysis demonstrated improvement across the many symptoms that were analysed. Quality of life analysis also established improvement. Statistically significant difference was achieved in several areas. Total physical symptoms (p value=.009) confirmed the positive impact attendance at SPCDU has on physical symptoms. Specific symptoms which displayed a statistically significant difference included: poor appetite (p value=.002), weakness (p value=.03) and the anxiety felt by family/friends (p value=.029). The quality of a patient's life also displayed statistically significant difference (p value=.000).

CONCLUSION

This study demonstrates that attendance at a SPCDU may positively impact a patients' symptoms and quality of life. A more uniform national approach to specialist palliative day care delivery, alongside multi-setting research, may further bolster the image of palliative day care. This will improve referrals to and occupancy of SPDCUs and benefit the palliative patient in the community.

Evaluation of an admission and discharge programme at a UK specialist palliative day hospice

This paper reports on a system of managing admissions and discharges from a specialist palliative day hospice (SPDH) in the south of England. SPDH is a well established component of palliative care provision in the UK, but studies have rarely addressed issues around admission and discharge. Case study methodology was used to evaluate the programme. Interviews were conducted with five patients who had attended the day hospice, taken a break or been discharged and returned; their carer(s); the key worker from the day hospice; and any other health professional who was involved in the patient's care during the admission. Communication issues were found within the team regarding referral and discharge processes, documentation of care, decision making, and information giving. Family members did not feel involved in decision making in relation to the programme. The most significant finding was the emotional and psychological impact on the patients of taking the break. Discharge from SPDH is known to be a difficult and sensitive issue, especially when patients are living with life-limiting illnesses that can change quickly. The patients in this study all had some form of dependency on the service and four of the five would have chosen to continue attending if they could. They experienced deterioration in psychological and physical wellbeing during the period in which they did not attend.

Negotiating the boundary between paid and unpaid hospice workers: a qualitative study of how hospice volunteers understand their work

OBJECTIVE

To explore the nurse-volunteer relationship in a day hospice.

METHOD

Underpinned by an interpretive approach, face-to-face semistructured interviews were conducted with 12 day hospice volunteers.

FINDINGS

The nature and dynamics of the relationship between nursing staff and volunteers within the day hospice were characterized by increasing formality and changes in the division of labor, which challenged smooth working relationships.

CONCLUSIONS

Volunteers see their role as becoming increasingly formalized partly as a response to increasing administrative demands on hospice nurses. The willingness of volunteers to take on new roles is variable. For volunteers to feel secure and valued and working relationships to remain strong, the process of how boundaries between paid and unpaid workers are negotiated needs to be transparent.

Patients' psychosocial experiences of attending Specialist Palliative Day Care: a systematic review

Recent reviews conclude that the benefits of attending Specialist Palliative Day Care (SPDC) are likely to be in social, psychological and spiritual domains. However, these areas are not easily identified, leaving researchers and practitioners unclear as to what aspects of these domains patients most need and desire. The objective of this review was to systematically evaluate literature on patient-perceived psychosocial experiences of attendance at SPDC. Twelve studies were included. Evidence showed that patients value a person-centred approach that reduces isolation, increases social support, encourages communication and provides activities. Future research could focus on investigating why patients value the psychosocial experiences reported and how these experiences can be defined in a way that would be meaningful to clinical service commissioners. Once this has been done, clinicians can start to measure more effectively clinical effectiveness and devise justifiable interventions to help this patient group.

The outcomes of palliative care day services: a systematic review

This systematic review evaluates the evidence underpinning the provision of palliative day care services (PDS) to determine whether such services have a measurable effect on attendees' wellbeing. The majority of studies reviewed were qualitative and elicited individual perceptions of the benefits PDS. Although it was difficult to determine the quality of many studies, it would appear that attendance at PDS had a positive impact on attendees' quality of life. Fewer studies utilized validated outcome measures to determine the effect of PDS on attendees' wellbeing and small sample sizes combined with high attrition rates influenced the significance of some the results. However little quantitative evidence was offered to prove that PDS had an impact on attendees' quality of life or wellbeing. The review concludes that dying people find attending PDS a valuable experience that allows them to engage with others and to be supported in a restorative environment. However, further well-powered empirical studies are required to provide quality evidence to determine whether or not attendance at PDS does indeed have a positive impact on the wellbeing of attendees.

Validity and reliability of the Japanese version of the Caregiver Reaction Assessment Scale (CRA-J) for community-dwelling cancer patients

BACKGROUND

The aim of this study was to validate the Caregiver Reaction Assessment (CRA) among caregivers of community-dwelling advanced cancer patients in Japan.

METHODS

A cross-sectional questionnaire was administered to advanced cancer patients and their caregivers who were cared for at day hospices and home palliative care services. We translated the CRA into Japanese, and then verified factor validity, reliability, construct validity, concurrent validity, and known groups' validity. To address construct and concurrent validity, we calculated Pearson's correlation coefficient between the Japanese version of the CRA and the Burden Index of Caregivers (BIC). To address known groups' validity, we used the t test or analysis of variance (ANOVA).

RESULTS

A total of 57 caregivers participated in the study. Five factors were extracted (''impact on schedule,'' ''caregiver's self-esteem,'' ''lack of family support,'' ''impact on health,'' and ''impact on finances'') and reliability was good. Construct and concurrent validity among the subscales of the BIC were good. Regarding known groups validity, the subscale score of ''impact on schedule'' for the groups that cared 6 hours or more per day was higher than the other group (P = .04).

CONCLUSION

The CRA-J is valid and reliable. This scale is useful for caregivers of cancer patients in Japan.

Quality of life, day hospice needs, and satisfaction of community-dwelling patients with advanced cancer and their caregivers in Japan

BACKGROUND

The aims of this study were to clarify (1) the quality of life (QOL) of community-dwelling patients with advanced cancer and their caregivers in home palliative care and day hospice settings, (2) the need for day hospice of home palliative care patients and caregivers, and (3) the satisfaction with day hospice by day hospice patients and caregivers.

METHODS

A cross-sectional questionnaire was administered to patients with advanced cancer and their caregivers who were cared for at day hospice and home palliative care. We measured the health-related quality of life using the SF-8, the need for day hospice of home palliative care patients and caregivers, and the satisfaction with day hospice by day hospice patients and caregivers.

RESULTS

A total of 57 pairs of patients and caregivers participated in the study (day hospice, n = 23; home palliative care, n = 34). The physical and mental aspects of the patient QOL were significantly lower than national standard value. However, although physical aspect of caregivers QOL was significantly lower than national standard value, mental aspect of caregiver's QOL was not lower than national standard value. Forty-four percent of home palliative care patients and 67% of home palliative care caregivers preferred day hospice. The needs of patients and caregivers were wide ranging including medical treatment, distraction, information provision, and respite. Overall, the Japanese day hospice was evaluated highly.

CONCLUSION

This is the first study of day hospice in Japan. Although there are several day hospices in Japan, the initiation of day hospice would probably be successful. The dissemination of day hospice is an important issue for patients with advanced cancer and their caregivers in Japan.

Social objectives in cancer care: the example of palliative day care

Social objectives are poorly specified and evaluated in cancer care. Palliative day care is an example where social objectives are often identified but research has focused on health-care outcomes. A literature review identifies four types of social objective: emotional and spiritual care, general social care, services for families and carers and creative arts. Social objectives include: distinguishing between therapeutic work and leisure and supportive interventions, promoting service continuity, reducing social isolation, increasing social interaction, reassuring introduction to palliative care, rehearsal of reactions to illness with a sympathetic audience, integration of families and carers into care services, respite for carers and creative work for three separable objectives. It is argued that interventions to achieve social objectives may be defined and evaluated in a measurable way. Similarly, social objectives and interventions can be specified at other stages in the cancer journey.

Heart failure and palliative care services working in partnership: report of a new model of care

It is widely acknowledged that people with advanced heart failure have at least as great a need for supportive and palliative care as those with malignant disease. However, specialist palliative care services are seldom involved in their care in the UK. We describe a three-year collaboration between community-based heart failure nurse specialists and existing specialist palliative care services. In the model of care that has evolved, the heart failure nurses remain key workers throughout the illness. They run a regular support group for patients and carers in the setting of a hospice day therapy unit, referring patients for other palliative care involvement as necessary. Activity data and the results of patient interviews are presented. These suggest that the model is a cost effective, sustainable way of providing high quality care for people with heart failure.

Patient satisfaction with hospice day care

Day hospice allows patients to remain living at home while attending a specialist palliative care center. This paper describes patient feedback (n=26) on medical, social and therapeutic out-patient palliative care services provided at one such facility in Northern Ireland. Medical records of all attending patients (n=50) were reviewed, and patients completed a semi-structured questionnaire. Patients' comments on day hospice were largely positive. A number of suggestions for new service activities were made, and the need for education of multi-professional team members was recognized. Respondents recognized that day hospice allowed respite care for the family. Patients were very appreciative of the care that was offered--their concern for its continuance perhaps restraining any criticism they had. Such findings provide the opportunity for health professionals to gain further insights into day care to better meet patients' needs.

Systematic review of specialist palliative day-care for adults with cancer

GOAL OF WORK

To inform future practice, research and policy in specialist palliative day-care by systematically reviewing the evidence for how the structure and process of this form of care relate to outcomes for adults with cancer.

PATIENTS AND METHODS

Medical, nursing and social science computerized databases were searched up until December 2003 for studies of palliative day-care reporting information on service structure, care processes or outcomes including symptom control, quality of life, social and psychological support, and patient and relative satisfaction with care. Qualitative and quantitative studies were assessed for methodological quality and graded, and the findings synthesized into the review.

MAIN RESULTS

Twelve observational studies were found that showed the difficulties of evaluating a service already operating and of recruiting a vulnerable population of patients as they deteriorated. Most services are nurse-led, but varied in the facilities, staff mix, care models, activities and places they offered. Patients attending seemed a selected group of those already receiving palliative care who were mostly white, aged over 60 years and retired, with needs for emotional and social support and pain control. There were insufficient studies to provide conclusive evidence of improved symptom control or health-related quality of life, but all qualitative studies found patients valued the social support and opportunity to take part in activities that day-care provided.

CONCLUSIONS

There is evidence for high satisfaction among patients selected into day-care, but not yet sufficient to judge whether this improves symptom control or health-related quality of life. Further research should explore selection and access into care, the most effective models of care, its cost, and potential benefits for relatives and carers. Comparison with models of care for older adults and those with mental illness would also be informative.

A qualitative evaluation of the impact of palliative care day services: the experiences of patients, informal carers, day unit managers and volunteer staff

OBJECTIVES

To explore the experiences of people involved in UK palliative care day services (PCDS) and identify the important outcomes of this service.

METHODS

Focus groups were carried out separately with patients, informal carers and volunteers from four purposively selected palliative care day units and with day unit managers from 11 units.

RESULTS

Patients benefited from both the support of PCDS professionals and social support of fellow PCDS patients, which contributed to a perceived improvement in their quality of life. Carers appreciated both the respite and support from PCDS, but acknowledged that they still had a poor quality of life. The challenges facing PCDS include the difficulties of discharging patients and the future role of volunteers.

DISCUSSION

PCDS improved patients' perceived quality of life and future evaluations on patient outcomes could use concepts such as self-esteem, self-worth and confidence. Future service provision could explore the possibility of a mixed service using both the traditional and appointment-based system.

Case studies: a research strategy appropriate for palliative care?

Selecting an appropriate research strategy is key to ensuring that research questions are addressed in a way which has value and is congruent with the overall topic, questions and purpose of the research. This paper will argue that there are situations when a case study strategy is appropriate to use in palliative care research. These include: when complex situations need to be addressed; when context is central to the study; when multiple perspectives need to be recognized; when the design needs to be flexible; when the research needs to be congruent with clinical practice; when there is no strong theory to which to appeal; and when other methodologies could be difficult to conduct. Using case study strategies rigorously and appropriately can contribute to knowledge in a way which is sensitive to the complex, context-dependent and multiprofessional nature of palliative care.