The experience of family members caring for a dying loved one

How Acculturation Influences Attitudes about Advance Care Planning and End-of-Life Care among Chinese Living in Taiwan, Hong Kong, Singapore, and Australia

Background: Understanding attitudes towards life and death issues in different cultures is critical in end-of-life care and the uptake of advance care planning (ACP) in different countries. However, existing research suffers from a lack of cross-cultural comparisons among countries. By conducting this comparative study, we hope to achieve a clear understanding of the linkages and differences among healthcare cultures in different Chinese societies, which may serve as a reference for promoting ACP by considering cultural differences. Methods: Our researchers recruited Chinese adults who could communicate in Mandarin and lived in metropolitan areas in Taiwan, Hong Kong, Singapore, and Australia. Focus group interviews were conducted, and the interview contents were recorded and subjected to thematic analysis. Results: Between June and July 2017, 14 focus groups with 111 participants were conducted in four regions. With traditional Chinese attitudes towards death as a taboo, many participants felt it would be challenging to discuss ACP with elderly family members. Most participants also desire to avoid suffering for the self and family members. Although the four regions’ participants shared a similar Chinese cultural context, significant regional differences were found in the occasions at which participants would engage in end-of-life discussions and select settings for end-of-life care. By contrast, participants from Singapore and Australia exhibited more open attitudes. Most participants from Taiwan and Hong Kong showed a preference for end-of-life care at a hospital. Conclusions: The developmental experiences of ACP in Western countries, which place a strong emphasis on individual autonomy, cannot be directly applied to family-centric Asian ones. Healthcare professionals in Asian societies should make continuous efforts to communicate patient status to patients and their family members to ensure family involvement in decision-making processes.

Caring and Conflict-Palliative Care in the Armed Forces: The Challenges for Caregivers

OBJECTIVES

In India, Palliative care remains inaccessible, especially in remote areas. This study aimed at exploring the experience of caregivers related to arranging palliative care at home, for personnel and family members of an armed force.

MATERIALS AND METHODS

Qualitative study based on thematic analysis of semi-structured interviews with adult caregivers - either serving personnel or their dependent family members.

RESULTS

Lack of palliative care in rural areas makes arranging home care challenging for Indian caregivers, especially in armed forces. The families stay alone and personnel cannot be there to look after loved ones. Constraints of leave, financial and legal problems, frequent movement and social isolation disrupt care as well as family and community support systems, leading to psycho-social problems and stress for the serving personnel as well as families. Educating staff, integrating palliative care into existing medical services, coordinating with other agencies to increase awareness and provide care at home, access to opioids, timely leave, reimbursement of expenses, increased family accommodation, guidance about benefits, and considerate implementation of transfer policy can help mitigate some of their problems.

CONCLUSION

These caregivers face physical exhaustion, psycho-social, financial, legal, and spiritual issues- some common to all rural Indians and others unique to the armed forces. Understanding their experiences will help the providers find solutions, especially in relation to the unique needs of the men in uniform.

A focused mapping review and synthesis of current practice in qualitative end of life research with the bereaved

BACKGROUND

Nursing research is dedicated to improving care, but research into end of life care can be challenging because of a possible reluctance by researchers to invite bereaved people to take part in studies.

AIM

To use a focused mapping approach to explore the recruitment to studies of grieving and bereaved people.

DISCUSSION

There is no 'gold standard' method of recruitment and no best way to approach participants. The outcome of each method, measured by the percentage of potential participants recruited, appears to be unrelated to the approach used.

CONCLUSION

There is no evidence that participation in research harms those who have recently been bereaved, but there is evidence of benefits from participating.

IMPLICATIONS FOR PRACTICE

Researchers should not feel they need to protect the bereaved from participating in research and can invite bereaved individuals to join a study without worrying about causing them harm.

Reminders of cancer risk and pain catastrophizing: relationships with cancer worry and perceived risk in women with a first-degree relative with breast cancer

First-degree relatives of women with breast cancer may experience increased worry or perceived risk when faced with reminders of their own cancer risk. Worry and risk reminders may include physical symptoms (e.g., persistent breast pain) and caregiving experiences. Women who engage in pain catastrophizing may be particularly likely to experience increased distress when risk reminders are present. We examined the degree to which persistent breast pain and experience as a cancer caregiver were related to cancer worry and perceived risk in first-degree relatives of women with breast cancer (N = 85) and how catastrophic thoughts about breast pain could impact these relationships. There was a significant interaction between persistent breast pain and pain catastrophizing in predicting cancer worry (p = .03); among women who engaged in pain catastrophizing, cancer worry remained high even in the absence of breast pain. Pain catastrophizing also moderated the relationships between caregiving involvement and cancer worry (p = .003) and perceived risk (p = .03). As the degree of caregiving responsibility increased, cancer worry and perceived risk increased for women who engaged in pain catastrophizing; levels of cancer worry and perceived risk remained low and stable for women who did not engage in pain catastrophizing regardless of caregiving experience. The results suggest that first-degree relatives of breast cancer survivors who engage in pain catastrophizing may experience greater cancer worry and perceived risk and may benefit from interventions aimed at reducing catastrophic thoughts about pain.

Meeting the needs of carers of people at the end of life

Carers have a vital role in end of life care in all settings. They are essential in enabling people to live at home at the end of their lives. Carers give and receive care, and have a range of support needs related to this complex role. This article explores the context of caring at the end of life and considers the experience of carers, in particular those who have a non-professional and unpaid relationship with someone who is at the end of life, and the support they require.

The preferences and perspectives of family caregivers towards place of care for their relatives at the end-of-life. A systematic review and thematic synthesis of the qualitative evidence

BACKGROUND

Home is often reported as the preferred place of care for patients at the end-of-life. The support of family caregivers is crucial if this is to be realised. However, little is known about their preferences; a greater understanding would identify how best to support families at the end-of-life, ensuring more patients are cared for in their preferred location.

OBJECTIVES

To systematically search and synthesise the qualitative literature exploring the preferences and perspectives of family caregivers towards place of care for their relatives at the end-of-life.

METHODS

Ten databases (MEDLINE, PsycINFO, EMBASE, AMED, ASSIA, CINAHL, Social Care Online, Cochrane Database, Scopus, Web of Science) and reference lists of key journals were searched up to January 2014. Included studies were appraised for quality and data thematically synthesised.

RESULTS

Eighteen studies were included; all were of moderate or high quality. Two main themes were identified: (1) Preferences and perspectives: most family caregivers preferred home care, although a range of perspectives were reported. Both positive and negative perspectives of home, hospices and hospitals emerged. At times, family caregivers reported feeling obligated to provide home care. (2) Impact of facilitating home care; both positive and negative effects on family caregivers were reported.

CONCLUSIONS

Many family caregivers reported home as the preferred place of care; other places of care were infrequently considered. Healthcare professionals and service providers should be aware of these preferences and provide support where needed to enable family caregivers to successfully care at home, thus improving end-of-life experiences for families as a whole.

Family Experiences in End-of-Life Care: A Literature Review

PURPOSE

The purpose of this study was to summarize and analyze families' experiences of end-of-life care by conducting a systematic review of peer reviewed journals both in Korea and abroad.

BACKGROUND

Families play an increasingly important role in care and medical treatment, acting as caregivers or decision makers rather than just being passive observers. It is necessary to understand the experiences of family members in order to provide appropriate care for them.

METHODS

A systematic search of the literature was performed using the Cumulative Index for Nursing and Allied Health Literature (CINAHL) and the Korea Education & Research Information Service (KERIS) for the period of January 1990 through to December 2006. A total of 35 studies met the inclusion criteria.

RESULTS

Seventeen studies used a quantitative design, while 18 studies used qualitative methods. Quantitative studies reported that the family's quality of life was relatively low when the patient was in need of high medical/nursing services. The perceived burden levels were moderately high, and depression levels were high among family caregivers. Various concepts emerged from the 18 qualitative studies, including psychological issues, physical problems, burdens, needs and interpersonal relationships.

CONCLUSION

This study found that most previous research findings were focused on negative and neutral experiences. A few studies identified positive experiences. Based on the study results, we suggest that nurses need to be more aware of the experiences of patients' families and their potential needs.

Dying at home: a qualitative study of the perspectives of older South Asians living in the United Kingdom

BACKGROUND

South Asians constitute the single largest ethnic minority group in the United Kingdom, yet little is known about their perspectives on, and experiences of, end-of-life care.

AIM

To explore beliefs, attitudes and expectations expressed by older South Asians living in East London about dying at home.

DESIGN

A qualitative study using focus groups and semi-structured interviews. Data were analysed using a constructivist grounded theory approach.

SETTING/PARTICIPANTS

Five focus groups and 29 in-depth semi-structured interviews were conducted with a total of 55 older adults (24 men and 31 women) aged between 52 and 78 years. Participants from six South Asian ethnic groups were recruited via 11 local community organisations.

RESULTS

Two key themes were identified. The theme of 'reconsidering the homeland' draws on the notion of 'diaspora' to help understand why for many participants, the physical place of death was perceived as less important than the opportunity to carry out cultural and religious practices surrounding death. The second theme 'home as a haven' describes participants' accounts of how their home is a place in which it is possible to perform various cultural and religious rituals. Cultural and religious practices were often seen as essential to achieving a peaceful death and honouring religious and filial duties.

CONCLUSIONS

Older people of South Asian ethnicity living in East London perceive home as more than a physical location for dying relatives. They make efforts to adhere, and also adapt, to important social and cultural values relating to death and dying as part of the wider challenge of living in an emigrant society.

A prospective study of family conferences: effects of patient presence on emotional expression and end-of-life discussions

CONTEXT

Limited research has taken place examining family conferences (FCs) with patients with advanced cancer and their caregivers in the palliative care setting.

OBJECTIVES

To characterize the FCs involving cancer patients in a palliative care unit at a comprehensive cancer center and examine the effects of patient participation on emotional expression by the participants and end-of-life discussions.

METHODS

A data collection sheet was completed immediately after 140 consecutive FCs that documented the number of participants, caregiver demographics, expressions of emotional distress, dissatisfaction with care, and the topics discussed. Patient demographics and discharge disposition also were collected.

RESULTS

Seventy (50%) patients were female, 64 (46%) were white, and 127 (91%) had solid tumors. Median age of patients was 59 years. Patients participated in 68 of 140 FCs (49%). Primary caregivers (n = 140) were female (66%), white (49%), and the spouse/partner (59%). Patients verbalized distress frequently (73%). Primary caregivers' verbal expression of emotional distress was high (82%) but not significantly affected by patient presence (82% vs. 82%, P = 0.936). Verbal expressions of emotional distress by other family members were more common when patients were absent (87%) than when present (73%), P = 0.037. Questions concerning advance directives (21%), symptoms anticipated at death (31%), and caregiver well-being (29%) were infrequent. Patient presence was significantly associated with increased discussions regarding goals of care (P = 0.009) and decreased communication concerning prognosis (P = 0.004) and what symptoms dying patients may experience (P < 0.001).

CONCLUSION

There was a high frequency of expression of emotional distress by patients and family members in FCs. Patient participation was significantly associated with decreased verbal emotional expression by family members but not the primary caregiver and was associated with fewer discussions regarding prognosis and what dying patients may experience.

Transition to an in-patient palliative care unit: carers share their experiences

BACKGROUND

For a carer, transitioning the care of a person who is dying to others may be a challenging experience. At this time, more than any other, carers' experiences need to be understood. The emotional impact of care transitions may have clinical significance for both carers and those they care for.

AIM

To explore carers experiences of the transition of the person they were caring for to in-patient care.

METHOD

Carers reflected on their. experiences through an explorative/descriptive research methodology.

RESULTS

Feelings of guilt and relief figured prominently in the participants' discourses.

CONCLUSIONS

Prominent feelings of guilt and relief overshadowed the participants' experiences of transitioning care. This finding needs to be considered by care providers.

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.

Death representation of caregivers in hospice

In this study, we investigated caregiver's death representation in hospice. The results presented here are a further analysis of the data collected in our previous study, concerning the evaluation of the caregiver in hospice. The data analysis of 24 caregivers of patients hospitalized in Rimini Hospice (Italy) underlined that caregivers avoiding death representation of the patient admitted to hospice had fewer protective factors (52.3%) and more risk factors (47.7%) than caregivers nonavoiding (66.5% and 33.5%, respectively). Caregivers avoiding death representation, moreover, experienced a greater distress (58%) than those nonavoiding (42%).

What are patients' priorities when facing the end of life? A critical review

This critical review aimed to investigate what patients' priorities are when facing the end of life, in order to gain further understanding of this issue. Academic databases were searched using key terms, and through a method of elimination and deduction using specific inclusion/exclusion criteria, suitable research studies were found. These articles were then assessed for their quality, and specific data was extracted from the final selection using appropriate information-gathering tools. In these final four articles the methodological processes used to explore terminally ill patients' needs were generally appropriate, although there was a lack of reflexivity (researcher reflection on the experience). Useful narrative themes were produced from all four papers for further discussion. The patients had similar priorities across all four articles, which were related to understanding and accepting their changing health status, the need to hold on to some normality in life, the need to feel supported by friends and family and to know they will be taken care of after the death, and the need to have good and trusting relationships with health professionals.

Struggling in an inescapable life situation: being a close relative of a person dependent on home enteral tube feeding

AIM

To explore what it means to be a close relative of a person dependent on home enteral tube feeding (HETF) and how they can manage this situation.

BACKGROUND

Previous studies have shown that the situation of close relatives in home care in general can be burdensome and difficult. Research is scarce about experiences of close relatives when patients are treated with HETF.

DESIGN

A qualitative design was used, in accordance with grounded theory (GT).

METHODS

Twelve close relatives were interviewed twice, using open-ended questions. Five were relatives of patients supported by home care services or advanced home care teams. Using the GT method, sampling, data collection and data analysis were carried out simultaneously.

RESULTS

One core category, 'Struggling in an inescapable life situation' and eight categories were found. The situation led to involuntary changes in the lives of the close relatives, something they could do little about. Their lives had become completely upturned and restricted by the HETF. Togetherness and pleasure was lost and they felt lonely. The relatives faced a new role of being informal caregivers and they had to adjust their daily life accordingly. They felt forced to take on a heavy responsibility for which they lacked support. The close relatives struggled to manage and to make the best of their new situation.

CONCLUSIONS

This study highlighted the demands and vulnerability which is embedded in the role of being a close relative of a patient with HETF. It also pointed out their need for comprehensive support from the health care system.

RELEVANCE TO CLINICAL PRACTICE

Support to facilitate the situation of close relatives should be given from the health care. One way to organise the care could be through a nurse-led clinic, which provides continuous support, information and counseling.

A desire to be seen: family caregivers' experiences of their caring role in palliative home care

Primary health care is the base of Swedish healthcare, and many terminally ill patients are cared for at home. A dying relative has a profound impact on his/her family members' situation, including negative effects on roles, well-being, and health. The aim of this study was to explore how the informal carers of a dying relative in palliative home care experienced their caring role and support during the patient's final illness and after death. Fourteen family members were selected in 4 primary health care areas in Sweden. Data were collected using open, tape-recorded interviews. A hermeneutic approach was used to analyze the data. The findings revealed that being an informal carer was natural when a relative became seriously ill. More or less voluntarily, the family member took on a caring role of control and responsibility. The informal carers felt left out and had feelings of powerlessness when they did not manage to establish a relationship with the healthcare professionals. For the informal carers to feel seen, it was necessary for them to narrate about their own supporting role.

Using syringe drivers in palliative care within a rural, community setting: capturing the whole experience

The aim of this research was to understand how the introduction of a syringe driver, which is considered routine practice in many palliative care settings, impacted on patients, carers and community nurses within a rural, community setting. A phenomenological study was conducted exploring the experiences from the perspective of patients (n=4), carers (n=9) and community nurses (n=12) when syringe drivers are used at home. We interviewed patients and carers in their own homes and conducted two focus groups with community nurses who had an interest in palliative care but were not specialists. Despite the wide use of syringe drivers within palliative care, our study found their use among community nurses, particularly in rural areas can be variable with frequent time lapses between a nurse's exposure, impacting on both their technical abilities and knowledge. In-depth interviews with patients revealed few barriers to their use, but carers clearly identified areas where their expectations and experiences differed and where more information setting realistic goals of care would have been helpful. The authors conclude that although nurses require competencies related to syringe drivers, they also need an in-depth knowledge of the actions of the drugs and the likely changes which occur physiologically as patients approach the end of their life. This will ensure accurate information is delivered, and facilitate meaningful dialogue.

A survey of emotional difficulties of nurses who care for oncology patients

Nurses who care for dying patients are under pressure emotionally because of their beliefs and values about death as well as the emotions and reactions of the patients and their families. This study examines the emotional difficulties of nurses caring for oncology patients in Turkey. The study used a descriptive survey design. The participants were 157 nurses from three medical oncology units in Ankara. Results showed that nurses had difficulty in talking to oncology patients about end-of-life issues and found that caring for dying patients affected their personal lives. This study also showed that the length of nurses' work experience had no effect on their feelings and perceptions toward terminally ill patients. However, the nurses who had more work experience were more likely to report difficulty in talking to patients. Most of the nurses expressed feelings of inadequacy and hopelessness about pain management and treatments.

End-of-life caregiver's perspectives on their role: generative caregiving

PURPOSE

To describe caregivers' constructions of their caregiving role in providing care to elders they knew were dying from life-limiting illnesses.

DESIGN AND METHODS

Study involved in-depth interviews with 27 family caregivers. Data were analyzed using constant comparative analysis.

RESULTS

Four categories were identified: centering life on the elder, maintaining a sense of normalcy, minimizing suffering, and gift giving. Generative caregiving was the term adopted to describe the end-of-life (EOL) caregiving role. Generative caregiving is situated in the present with a goal to enhance the elder's present quality of life, but also draws from the past and projects into the future with a goal to create a legacy that honors the elder and the elder-caregiver relationship.

IMPLICATIONS

Results contribute to our knowledge about EOL caregiving by providing an explanatory framework and setting the caregiving experience in the context of life-span development.

The use of cognitive continuum theory and patient scenarios to explore nurse prescribers’ pharmacological knowledge and decision-making

BACKGROUND

Nurses have been involved in prescribing in England since 1996, and to date over 41,000 nurses are registered with the Nursing and Midwifery Council as prescribers. The majority of evaluative research on nurse prescribing is descriptive and relies on self-report and assessment of patient satisfaction.

OBJECTIVES

To explore and test nurse prescribers' pharmacological knowledge and decision-making.

DESIGN

An exploratory approach to test the usefulness of patient scenarios in addressing the reasons why nurses decide whether or not to prescribe was utilised. Semi-structured interviews with nurse prescribers using patient scenarios were used as proxy methods of assessment of how nurses made their prescribing decisions.

SETTING

Two primary care trusts in the southeast of England were the settings for this study.

PARTICIPANTS

Purposive sampling to ensure there was a mixed group of prescribers was used to enable detailed exploration of the research objectives and to obtain in-depth understanding of the complex activities involved in nurse prescribing.

METHODS

Interviews and case scenarios. The use of cognitive continuum theory guided the analysis.

RESULTS

The majority of participants were unable to identify the issues involved in all the scenarios; they also failed to provide an acceptable solution to the problem, suggesting that they would refer the patient to the general practitioner. A similar number described themselves as 'very confident' while seven participants felt that they were 'not confident' in dealing with medication issues, four of whom were practising prescribing.

CONCLUSIONS

The effects of social and institutional factors are important in the decision-making process. The lack of appropriate pharmacological knowledge coupled with lack of confidence in prescribing was demonstrated. The scenarios used in this study indicate that nurses are perhaps knowledgeable in their small area of practise but flounder outside this. Further research could be conducted with a larger sample and with more scenarios to explore the decision-making and the pharmacological knowledge base of nurse prescribers, particularly in the light of government policy to extend prescribing rights to non-medical prescribers, including pharmacists.

Non-finite loss and emotional labour: family caregivers? experiences of living with motor neurone disease

AIM AND OBJECTIVES

This paper aims to add to nurses' knowledge concerning the losses and emotional labour family caregivers face caring for people living with neurodegenerative, life-limiting illnesses such as motor neurone disease.

BACKGROUND

Motor neurone disease is a relentless, progressive illness resulting in progressive loss of voluntary muscle mass and function. Previous caregiver research presents the salient losses such as social, financial and relationship loss. However, the non-finite, unpredictable losses faced every day by caregivers and the emotional labour experienced are not effectively represented and have not been explored for caregivers of adult patients with life-limiting, degenerative, illness.

DESIGN/METHODS

Semi-structured interviews, ecomaps of social support networks and field notes were used to collect data for this ethnographic case study. Data were attained at three time points over a 10-month period from 18 primary caregivers and once from six peripheral caregivers.

RESULTS

Data revealed new information about the psychosocial and emotional losses experienced daily, when living with motor neurone disease. The impact of the constancy of voluntary muscle degeneration and the uncertainty of the illness progression in terms of available time and functional loss, threatened people's understanding and expectations of life, their relationships, their personal identity and their future. Managing their relationship with the patient and their reactions to the devastation of motor neurone disease is consistent with the concept of emotional labour.

CONCLUSIONS

Family caregivers living with relentless, life-limiting illness experience non-finite losses and emotional labour on a daily basis. While each individual's experience of loss is unique, nurses need to include caregivers as well as patients, in their spectrum of supportive care.

RELEVANCE TO CLINICAL PRACTICE

Nurses can be independent confidants who share the emotional labour and work with caregivers to develop interventions to assist them to manage their losses and their changing needs for psychological and emotional support.

From Husserl to van Manen. A review of different phenomenological approaches

This paper traces the development of phenomenology as a philosophy originating from the writings of Husserl to its use in phenomenological research and theory development in nursing. The key issues of phenomenological reduction and bracketing are also discussed as they play a pivotal role in the how phenomenological research studies are approached. What has become to be known as "new" phenomenology is also explored and the key differences between it and "traditional" phenomenology are discussed. van Manen's phenomenology is also considered in light of its contemporary popularity among nurse researchers.

Patients and their families

The focus of this chapter is on how clinicians can understand and communicate with the families of patients suffering from cancer. Most doctors and nurses do not have training in this area and are uncomfortable when conducting interviews with whole families. The need to extend our skills in the family context reflects the changes in the way care is provided to patients with a serious illness. We recognise the part families play in providing care and the subsequent effects on family life. The influence of systemic thinking and social construction theories has led to the acknowledgement that we are all part of systems which interact with each other and it is no longer appropriate to see the patient in isolation. The chapter will look at ideas from family therapy which can help us assess and intervene when necessary. The patient suffering from a life-threatening illness such as cancer looks to his family and friends for care and support. The management and course of the illness is affected by the involvement of the family and how they manage the stress and the effects of illness on a family member (Wright and Leahey 2000). Duhamel and Dupuis (2003) point out that there are three important factors in the management of the illness: the effects of family stress, the needs of the family as caregivers, and the effects of the role and how the family cope with the way the patient experiences his illness. This presents professionals working in the field with challenges they are often ill-equipped to deal with. Most healthcare workers have inadequate training in understanding family dynamics and even less knowledge about how to communicate effectively with whole families. Consequently, many healthcare professionals avoid couple and family interviews, feeling inadequate and helpless like the families themselves. I will address some of these issues in the chapter, firstly by examining what we now regard as the family and then by using ideas from systemic theory I will look at assessing families, the organisation of families and belief systems, concluding with communications which can bring about change in families needing our help. Families are complex, they have histories and are influenced by the past. Relationships within families have different meanings and significance not understood unless questions that we ask bring access to them; moreover, their journeys through the illness of the family member is different from that of the patients. However, the need for support/information/valuing/respect is the same. If we are to help, we need to know how to approach families, how to asses their needs, and learn about interventions that help so that we can offer holistic care which will ease the practical, physical, emotional, social and spiritual pain and suffering of the people who will go on living with the significance of the death.

Relatives in end-of-life care--part 1: a systematic review of the literature the five last years, January 1999-February 2004

AIM

To review systematically research conducted during the past five years focusing on the relatives' situation and needs in end-of-life care.

BACKGROUND AND AIM

That relatives make a large contribution in the care of the dying is well-known. In this situation, relatives often have to solve many new practical problems in the care as well as dealing with the sorrow of both themselves and the dying person. In recent years, palliative care has been developed in many countries and many new studies have been carried out.

METHODS

A systematic search of the literature was performed in the CINAHL and Medline databases. Of the 94 papers analysed, there were 59 qualitative and 35 quantitative studies with differing designs. The studies were carried out in 11 countries and were published in 34 different journals.

RESULTS

The results were categorized in two main themes with several subthemes: (1) being a close relative--the situation: (i) exposed position--new responsibility, (ii) balance between burden and capacity and (iii) positive values; (2) being a close relative--needs: (i) good patient care, (ii) being present, (iii) knowing and communicating and (iv) support from and trusting relationship with the professional. The relative's feelings of security and trust in the professional were found to be of great importance.

CONCLUSION

More than twice as many studies had a descriptive/explorative design, which is of importance in the assessment of evidence. However, different studies complement one another and in summary, it can be said that analytic evidence is unequivocal: good patient care, communication, information and the attitude of the professional are of decisive importance regarding relatives' situation. These results are also in accord with earlier review studies.

RELEVANCE TO CLINICAL PRACTICE

Staff members have a great deal of responsibility for assuring that the patient feels as good as possible, facilitating relatives' involvement based on the family's wishes and limiting the stress and difficulties experienced by the family. The results showed that the relative's satisfaction could depend on the attitude of the professional as well as on good communication, good listening and good information. This can also be viewed as a prerequisite for the professional to get to know the family and to provide 'care in the light'.

End-of-life care in community hospitals: the perceptions of bereaved family members

OBJECTIVES

The perceptions of bereaved family members were obtained to evaluate the nature and quality of end-of-life care in community hospitals.

DESIGN

During organizational case studies in six community hospitals in the South East and South West of England, bereaved family members were asked to participate in semi-structured interviews.

PARTICIPANTS

Fifty-one interviews were conducted with family members of patients who had received end-of-life care in a community hospital within the previous year.

RESULTS

Respondents were very positive about the care they and the patient had received. They valued the convenience of access for frequent and long-stay visiting and the familiarity of the local hospital. Comparisons were made with more negative experiences at their nearest District General Hospital. Issues raised included the noise at the community hospitals, and the lack of contact with qualified nurses.

DISCUSSION

The results of this study have implications for UK government initiatives, such as the National Framework for Older People, and the Department of Health's 'Keeping the NHS Local'.

Who's there and who cares: age as an indicator of social support networks for caregivers among people living with motor neurone disease

This paper explores the social support networks available to the informal carers of people living with motor neurone disease (MND). An ethnographic case study was undertaken using eco mapping, observation and conversational interviews to collect data from 18 primary carers of people living with MND. Interviews took place in participants' homes in metropolitan, regional and rural locations. Participants discussed the content of their support network and drew lines between individuals to indicate the type and strength of relationship. Changes to the network were depicted on eco maps during subsequent interviews. While health policy-makers assume that healthy social capital exists in Australian communities and that social cohesion will ensure active and available support networks in times of illness or disability, data from this exploratory study indicated that this was not consistently the case. Support networks varied in size and composition; however, age was identified as a discriminator of the availability and consistency of support. People in older age groups identified more diverse but consistent support systems while people in younger age groups reported more fluctuations in the strength of relationships and declines in support as caregiving became more demanding. Individual assessment of support networks at regular intervals in the caregiving trajectory is vital for all carers. However carers in younger age groups may need specific support to manage the psychological crises that occur and more access to paid care. Older carers may need consistent support to handle more of the instrumental aspects of care and assistance to mobilise their support networks. Community workers should be alert to the possible need for crisis intervention when tensions in relationships threaten carers' ability to provide effective care.