Palliative care as a framework for older people’s long-term care

Older persons' thoughts about death and dying and their experiences of care in end-of-life: a qualitative study

Background

Few studies have focused on how older persons living in nursing homes perceive their last period of life. Furthermore, previous research on older persons’ perceptions of death and dying is limited. Hence, there is an urgent need to explore their experiences during their final period in life.

Aim

To explore thoughts about death and dying and experiences of care in end-of-life among older persons living in nursing homes.

Methods

This study employed a qualitative approach including individual interviews with 36 older persons living in Swedish nursing homes. Questions related to quality of life; physical health; thoughts about death, dying, and the future; and experiences related to the living condition and environment were asked. The interview transcripts were analysed through content analysis. The study was approved by the Regional Ethics Review Board (reference number: 2015/4).

Results

The analysis resulted in the identification of three main thematic categories: The unavoidable and unknown end of life, Thoughts on control and Living your last period of life at a nursing home. The older persons did not fear death itself but had some worries about dying. Spending the last stage of life at a nursing home contributed to different thoughts and feelings among the older persons. With a few exceptions, older persons characterized life at the nursing home as boring and felt they were surrounded by people who did not belong there.

Conclusions

This study indicates a need for older persons to talk about death, dying and end-life issues. Furthermore, this study highlighted that the co-residence of cognitively healthy persons and persons with dementia in the same ward adversely affected cognitively healthy persons. This situation resulted in there being not enough time to both handle the care needs of persons with dementia and have the conversations that cognitively healthy persons desired, such as conversations about thoughts about existence, that could have improved their quality of life.

Trial registration

NCT02708498 Date of registration 16 February 2016.

Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care

Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.

A Pilot Study on the effectiveness of Anticipatory Grief Therapy for Elderly Facing the end of Life

This pilot study evaluates the benefits of anticipatory grief therapy (AGT) for day hospice patients and long-term care (LTC) residents with cancer and non-malignant chronic diseases. Twenty-six elderly people (69.2 percent female; average age 81.8 years) participated in experiential, expressive activities and discussions during AGT. The McGill Quality of Life Questionnaire-Hong Kong version and the 15-item Geriatrics Depression Scale (Chinese version) were administered immediately before and after AGT, and at a four-week follow-up. Focus groups were held to collect qualitative feedback. Significant post-AGT improvements were found in physical (Z=-2.12, p<0.05), psychological (Z=-2.22, p<0.05), and total quality of life measures (Z=-2.66, p<0.01), and in depression levels (Z=-2.49, p<0.05). Emergent qualitative themes included grief and existential concerns, pros and cons of reminiscence, reflection and affirmation of meaning through expressive art, perceived benefits of AGT, and comments and suggestions for improving AGT in the future. We conclude that AGT delivered in both day hospice and LTC settings could be acceptable, feasible, and useful for elderly people facing the end of life.

Palliative care during the final week of life of older people in nursing homes: A register-based study

Objective:

Our aim was to explore the presence of symptoms, symptom relief, and other key aspects of palliative care during the final week of life among older people residing in nursing homes.

Method:

Our study employed data from the Swedish Palliative Care Register on all registered individuals aged 60 and older who had died in nursing homes during the years 2011 and 2012. Variables pertaining to monitoring and treatment of symptoms, end-of-life discussions, circumstances around the death, and the individual characteristics of deceased individuals were explored using descriptive statistics.

Results:

The most common underlying causes of death among the 49,172 deceased nursing home residents were circulatory diseases (42.2%) and dementia (22.7%). The most prevalent symptom was pain (58.7%), followed by rattles (42.4%), anxiety (33.0%), confusion (21.8%), shortness of breath (14.0%), and nausea (11.1%). Pain was the symptom with the highest degree of total relief (46.3%), whereas shortness of breath and confusion were totally relieved in 6.1 and 4.3% of all individuals, respectively. The use of valid instruments for symptom assessment was reported for pain in 12.3% and for other symptoms in 7.8% of subjects. The most prevalent individual prescriptions for injection PRN (pro re nata, according to circumstances) were for pain treatment (79.5%) and rattles (72.8%). End-of-life discussions were performed with 27.3% of all the deceased individuals and with 53.9% of their relatives. Of all individuals, 82.1% had someone present at death, and 15.8% died alone. Of all the nursing home resident deaths recorded, 45.3% died in their preferred place.

Significance of results:

There were large variations in degree of relief from different symptoms during the final week of life. Pain was the most prevalent symptom, and it was also the symptom with the highest proportion of total/partial relief. Other symptoms were less prevalent but also less well-relieved. Our results indicate a need for improvement of palliative care in nursing home settings, focusing on management of distressing symptoms and promotion of end-of-life discussions.

First-Line Nursing Home Managers in Sweden and their Views on Leadership and Palliative Care

The aim of this study was to investigate first-line nursing home managers’ views on their leadership and related to that, palliative care. Previous research reveals insufficient palliation, and a number of barriers towards implementation of palliative care in nursing homes. Among those barriers are issues related to leadership quality. First-line managers play a pivotal role, as they influence working conditions and quality of care.

Nine first-line managers, from different nursing homes in Sweden participated in the study. Semi-structured interviews were conducted and analysed using qualitative descriptive content analysis. In the results, two categories were identified: embracing the role of leader and being a victim of circumstances, illuminating how the first-line managers handle expectations and challenges linked to the leadership role and responsibility for palliative care. The results reveal views corresponding to committed leaders, acting upon demands and expectations, but also to leaders appearing to have resigned from the leadership role, and who express powerlessness with little possibility to influence care. The first line managers reported their own limited knowledge about palliative care to limit their possibilities of taking full leadership responsibility for implementing palliative care principles in their nursing homes.

The study stresses that for the provision of high quality palliative care in nursing homes, first-line managers need to be knowledgeable about palliative care, and they need supportive organizations with clear expectations and goals about palliative care. Future action and learning oriented research projects for the implementation of palliative care principles, in which first line managers actively participate, are suggested.

The last three days of life: a comparison of pain management in the young old and the oldest old hospitalised patients using the Resident Assessment Instrument for Palliative Care

BACKGROUND

Pain is a common symptom in older patients at the end of life. Little research has evaluated pain management among the oldest hospitalised dying patients.

AIMS AND OBJECTIVES

To compare the pain characteristics documented by healthcare workers for the young old and the oldest old hospitalised patients and the types of analgesics administered in the last three days of life.

DESIGN

A retrospective cross-sectional comparative study.

METHODS

The study included 190 patients from a Norwegian general hospital: 101 young old patients (aged 65-84 years) and 89 oldest old patients (aged 85-100 years). Data were extracted from electronic patient records (EPRs) using the Resident Assessment Instrument for Palliative Care.

RESULTS

No significant differences were found between the young old and the oldest old patients with regard to pain characteristics. Pain intensity was poorly recorded in the EPRs. Most of the patients received adequate pain control. Morphine was the most frequently administered analgesic for dying patients. Compared to the oldest old patients, a greater proportion of the young old patients received paracetamol combined with codeine (OR = 3.25, 95% CI 1.02-10.40).

CONCLUSIONS

There appeared to be no differences in healthcare workers' documentation of pain characteristics in young old and oldest old patients, but young old patients were more likely to receive paracetamol in combination with codeine.

IMPLICATIONS FOR PRACTICE

A limitation of the study is the retrospective design and that data were collected from a single hospital. Therefore, caution should be taken for interpretation of the results. The use of systematic patient-reported assessments in combination with feasible validated tools could contribute to more comprehensive documentation of pain intensity and improved pain control.

Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study

Introduction

The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient's health status and individual needs. The objective of this study was to identify and describe the process and content of the patient information exchange between nurses in home care and hospital during hospitalization of older home-living patients.

Methods

A multiple case study design was used. Using observations, qualitative interviews and document reviews, the total patient information exchange during each patient's episode of hospitalization (n = 9), from day of admission to return home, was captured.

Results

Information exchange mainly occurred at discharge, including a discharge note sent from hospital to home care, and telephone reports from hospital nurse to home care nurse, and meetings between hospital nurse and patient coordinator from the municipal purchaser unit. No information was provided from the home care nurses to the hospital nurses at admission. Incompleteness in the content of both written and verbal information was found. Information regarding physical care was more frequently reported than other caring dimensions. Descriptions of the patients’ subjective experiences were almost absent and occurred only in the verbal communication.

Conclusions

The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange.

In search of legitimacy--registered nurses' experience of providing palliative care in a municipal context

BACKGROUND

The palliative care approach was originally developed for hospice care and for persons with cancer diseases, but has gradually expanded to embrace other contexts and people of all ages, with various life-threatening diseases. The palliative care concept thus also applies to older people and the context of municipal care, where Registered Nurses (RNs) hold key care provision positions. The municipal context is not, however, focused primarily on advanced nursing care, and it is important to highlight RNs' prerequisites for care provision.

AIM

The study's aim was to describe RNs' experience of providing palliative care for older people in a municipal context. Data were collected through focus group discussions with 20 RNs from four different municipalities in southern Sweden and were analysed using conventional content analysis.

FINDINGS

The results showed that the nurses experienced that it was they who cushioned the effects of unclear responsibilities between different organizations, but had limited legitimacy in the municipal context and in relation to other care providers. The results also showed that nurses lacked proper support and prerequisites for providing high-quality palliative care to older dying patients.

CONCLUSION

The results pinpoint the importance of increased acknowledgement of nurses' knowledge and skills and a critical view on the effects of moving towards an organization composed of different consultants, which can lead to even more unclear responsibility for nursing care provision.

Last three days of life in the hospital: a comparison of symptoms, signs and treatments in the young old and the oldest old patients using the Resident assessment instrument for palliative care

BACKGROUND

Knowledge concerning the provision of end of life care to the oldest old hospitalised patients is deficient.

AIMS AND OBJECTIVES

To analyse whether there were differences in registered nurses' documentation of the young old vs. the oldest old patients according to symptoms, clinical signs and treatment in the last 3 days of life.

DESIGN

Data were collected retrospectively in a cross-sectional comparative study at a hospital between autumn 2007 and spring 2009. Methods.  The study included 190 patients: 101 (65-84 years) and 89 (85+). Data were extracted from the patients' electronic records using the Resident Assessment Instrument for Palliative Care (RAI-PC).

RESULTS

Falls (OR = 4.01, 95% CI 1.47-10.90) and peripheral oedema (OR = 2.74, 95% CI 1.06-7.11) were significantly more frequent documented in the oldest old patients compared with the young old patients. Delirium was recorded in 15.3% of all patients.

CONCLUSION

With the exception of more falls and peripheral oedema in the oldest old patients, this study showed no differences in symptoms and treatment between the young old and the oldest old patients. Delirium was poorly documented compared to other studies. Implications for practice.  The oldest old patients have a higher risk of falls in the final phase of life, and fall prevention should be considered.

Having to focus on doing rather than being-nurse assistants' experience of palliative care in municipal residential care settings

BACKGROUND

Palliative care should be provided, irrespective of setting to all patients facing a life-threatening illness and to their families. The situation and needs of older people differ from those of younger people since they often have several co-existing diseases and health complaints. This implies an extensive need for care and for longer periods of palliative care. The main providers of palliative care for older people are nurse assistants, who are also those with the shortest education.

AIM

The aim of this study was to illuminate nurse assistants' experience of palliative care for older people in residential care.

DESIGN

The study had an explorative, descriptive design.

SETTINGS

Thirteen residential care units in three different districts in a large city in southern Sweden.

PARTICIPANTS

Twenty-five nurse assistants selected to represent variations in age, gender workplace and work experience.

METHODS

Data were collected from six focus-group interviews and subjected to content analysis to gain an understanding of the phenomenon.

RESULTS

The nurse assistants described palliative care as a contrast to the everyday care they performed in that they had a legitimate possibility to provide the care needed and a clear assignment in relation to relatives. Palliative care also meant having to face death and dying while feeling simultaneous that it was unnatural to talk about death and having to deal with their own emotions. They emphasised that they were in need of support and experienced leadership as invisible and opaque, but gained strength from being recognized.

CONCLUSION

In order to support nurse assistants in providing high quality end-of-life care, more focus is needed on the trajectory of older peoples' dying, on the importance of involving relatives throughout the period of care provision, and on support when encountering death and dying. There is also a need for engaged care leaders, both registered nurses and managers, to recognize the work of nurse assistants and to support care provision for older people within the framework of palliative care philosophy.

Providing end-of-life care in care homes for older people: a qualitative study of the views of care home staff and community nurses

The study aimed to explore the views of care home staff (CHS) and community nurses (CNs) on providing end-of-life care (EOLC) in care homes. Participants were randomly selected and qualitative interviews conducted with 80 CHS and 10 CNs. Themes emerging from the data included the following: The meaning of EOLC; starting EOLC; dying in the care home; stress of providing EOLC; improving EOLC; and the role of the CN. CHS felt that planning for the end of life was important before residents reached the dying phase, which some found difficult to determine. Although CHS wished to avoid residents being transferred to hospital to die, they acknowledged that improvements in their skills and the resources available to them were needed to manage EOLC effectively. CNs were critical of the EOLC provided in some care homes, reporting tensions over their relationship with CHS. As the number of older people who die in care homes increases, there is a need to overcome these barriers to provide good EOLC.

Predicting mortality of residents at admission to nursing home: a longitudinal cohort study

Background

An increasing numbers of deaths occur in nursing homes. Knowledge of the course of development over the years in death rates and predictors of mortality is important for officials responsible for organizing care to be able to ensure that staff is knowledgeable in the areas of care needed. The aim of this study was to investigate the time from residents' admission to Icelandic nursing homes to death and the predictive power of demographic variables, health status (health stability, pain, depression and cognitive performance) and functional profile (ADL and social engagement) for 3-year mortality in yearly cohorts from 1996-2006.

Methods

The samples consisted of residents (N = 2206) admitted to nursing homes in Iceland in 1996-2006, who were assessed once at baseline with a Minimum Data Set (MDS) within 90 days of their admittance to the nursing home. The follow-up time for survival of each cohort was 36 months from admission. Based on Kaplan-Meier analysis (log rank test) and non-parametric correlation analyses (Spearman's rho), variables associated with survival time with a p-value < 0.05 were entered into a multivariate Cox regression model.

Results

The median survival time was 31 months, and no significant difference was detected in the mortality rate between cohorts. Age, gender (HR 1.52), place admitted from (HR 1.27), ADL functioning (HR 1.33-1.80), health stability (HR 1.61-16.12) and ability to engage in social activities (HR 1.51-1.65) were significant predictors of mortality. A total of 28.8% of residents died within a year, 43.4% within two years and 53.1% of the residents died within 3 years.

Conclusion

It is noteworthy that despite financial constraints, the mortality rate did not change over the study period. Health stability was a strong predictor of mortality, in addition to ADL performance. Considering these variables is thus valuable when deciding on the type of service an elderly person needs. The mortality rate showed that more than 50% died within 3 years, and almost a third of the residents may have needed palliative care within a year of admission. Considering the short survival time from admission, it seems relevant that staff is trained in providing palliative care as much as restorative care.

A discourse of silence: professional carers reasoning about death and dying in nursing homes

Nursing homes are a setting in which death and dying is common. How death and dying is articulated and the actions that take place in a nursing home constitute a discourse that guides the staff in their work. The aim of this study was to explore the discourse of death and dying in nursing homes from the perspective and understanding of the staff. The study draws on Foucault's discourse analysis. Data are from five focus-group discussions held with 28 staff of four different nursing homes in Sweden. The findings show that the discourse had three characteristics: (a) dying was silent and silenced, (b) emotions were pushed into the background, and (c) attentiveness to death arose after the moment of the elderly person's death. The structure of the discourse was characterised by a movement between two positions, avoiding and confronting death, the main focus being on avoidance. The articulation and practices of silence highlight a need to regard dying as a process that requires attention. One way to ensure appropriate attention could be to instil the philosophy of palliative care in nursing homes, including training and support for the staff in their work. The study demonstrates that nursing-home staff need more knowledge and support to enable them to feel that they do a good job.

Principles of good care for long-term care facilities

BACKGROUND

The International Psychogeriatric Association Task Force on Mental Health Services in Long-Term Care Facilities aims to support and strengthen mental health services in the long-term care sector. The purpose of this paper is to identify broad principles that may underpin the drive towards meeting the mental health needs of residents of long-term care facilities and their families, as well as to enhance the overall delivery of residential care services.

METHODS

Principles of good care are extrapolated from an analysis of international consensus documents and existing guidelines and discussed in relation to the research and practice literature.

RESULTS

Although the attention to principles is limited, this review reveals an emerging consensus that: (1) residential care should be situated within a continuum of services which are accessible on the basis of need; (2) there should be an explicit focus on quality of care in long-term care facilities; and (3) quality of life for the residents of these facilities should be a primary objective. We take a broad perspective on the challenges associated with actualizing each of these principles, taking into consideration key issues for families, facilities, systems and societies.

CONCLUSIONS

Recommendations for practice, policy and advocacy to establish an internationally endorsed principles-based framework for the evolution and development of good mental health care within long-term care facilities are provided.

End-of-life care in the oldest old

Objective:

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

Method:

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

Results:

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

Significance of results:

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

Palliative care for the elderly--developing a curriculum for nursing and medical students

BACKGROUND

Delivering palliative care to elderly, dying patients is a present and future challenge. In Germany, this has been underlined by a 2009 legislation implementing palliative care as compulsory in the medical curriculum. While the number of elderly patients is increasing in many western countries multimorbidity, dementia and frailty complicate care. Teaching palliative care of the elderly to an interprofessional group of medical and nursing students can help to provide better care as acknowledged by the ministry of health and its expert panels. In this study we researched and created an interdisciplinary curriculum focussing on the palliative care needs of the elderly which will be presented in this paper.

METHODS

In order to identify relevant learning goals and objectives for the curriculum, we proceeded in four subsequent stages. We searched international literature for existing undergraduate palliative care curricula focussing on the palliative care situation of elderly patients; we searched international literature for palliative care needs of the elderly. The searches were sensitive and limited in nature. Mesh terms were used where applicable. We then presented the results to a group of geriatrics and palliative care experts for critical appraisal. Finally, the findings were transformed into a curriculum, focussing on learning goals, using the literature found.

RESULTS

The literature searches and expert feedback produced a primary body of results. The following deduction domains emerged: Geriatrics, Palliative Care, Communication & Patient Autonomy and Organisation & Social Networks. Based on these domains we developed our curriculum.

CONCLUSIONS

The curriculum was successfully implemented following the Kern approach for medical curricula. The process is documented in this paper. The information given may support curriculum developers in their search for learning goals and objectives.

Nursing home residents' views on dying and death: nursing home employee's perspective

AIM

To reveal nursing home employees' views on dying and death among older people they cared for.

BACKGROUND

Palliative care stakeholders recently included more groups in their definition of palliative care; older people constitute one such group. Consequently, palliative care systems, which will serve a large, aging cohort, will require new skills. The first stage in skills acquisition is to gather current views on dying and death.

DESIGN

Qualitative descriptive study that uses focus group discussions for data collection; 20 employees in 4 Swedish nursing homes participated.

METHOD

Data were analysed using qualitative content analysis.

RESULTS

The following categories were conceptualised: alleviating suffering and pain; finding meaning in everyday life; revealing thoughts and attitudes about death; taking care of the dead person's body; and coping with the gap between personal ideals and reality.

CONCLUSIONS

A deeper understanding of the palliative care philosophy is needed to further develop and tailor care for the dying persons in nursing homes.

RELEVANCE TO CLINICAL PRACTICE

To get public support for palliative care, the silence surrounding dying and death must be broken. Employees must receive education to prepare for all aspects of their work, and management must account for employees' situation when planning the care.

Reducing the potential for suffering in older adults with advanced cancer

Objective:

To deliver quality care at the end of life, understanding the impact of various changes and life transitions that occur in older age is essential. This review seeks to uncover potential sources of distress in an elder's physical, psychological, social, and spiritual well-being to shed light on the unique challenges and needs facing this age group.

Methods:

Papers relating to older adults (aged 65 years and older or a mean age of 65 years and older) with advanced/terminal cancer receiving palliative, hospice, or end-of-life care published after 1998 were reviewed.

Results:

Older adults with advanced cancer have unique needs related to changes in their physical, psychological, social, and spirituals well-being. Changes in each of these domains offer not only the risk of causing distress but also the potential for growth and development during the final stages of advanced cancer.

Significance of results:

Being aware of the various changes that occur with aging will help health care professionals tailor interventions to promote dignity-conserving care and greatly reduce the potential for suffering at the end of life.

A critical literature review exploring the challenges of delivering effective palliative care to older people with dementia

AIM

This paper considers the challenges of delivering effective palliative care to older people with dementia and the possible strategies to overcome barriers to end-of-life care in these patients.

BACKGROUND

In UK alone, approximately 100,000 people with dementia die each year and as the number of older people increases, dementia is set to become even more prevalent. Dementia is a progressive terminal illness for which there is currently no cure. Patients dying with dementia have significant health-care needs and in recent years it has been recognised that palliative care should be made available to everyone regardless of diagnosis, as this improves comfort and quality of life. Despite this, patients dying with dementia are often still not given access to palliative care services.

METHOD

A review of English language literature published after 1996 to the present day relating to older people with dementia during the terminal phase of their illness.

RESULTS

Twenty-nine articles met inclusion criteria for the review. Most originated from North America and UK and were mostly quantitative in nature. Four key themes were identified: difficulties associated with diagnosing the terminal phase of the illness (prognostication); issues relating to communication; medical interventions; and the appropriateness of palliative care intervention.

CONCLUSIONS

This review reinforces the importance of providing appropriate palliative care to individuals suffering from end-stage dementia and identifies some of the barriers to extending such specialist palliative care provision.

RELEVANCE TO PRACTICE

There is an urgent need to improve palliative care provision for older people with end-stage dementia and, in addition, more research is required on the needs of patients entering the terminal phase of dementia to assist the allocation of appropriate resources and training to ensure quality and equality in the provision of end-of-life care.

Palliative care for people with Alzheimer's disease

The task of aligning the philosophical and clinical perspectives on ethics is a challenging one. Clinical practice informs philosophy, not merely by supplying cases, but through shaping and testing philosophical concepts in the reality of the clinical world. In this paper we explore several aspects of the relationship between the philosophical and the clinical within a framework of palliative care for people living with Alzheimer's disease. We suggest that health professionals have a moral obligation to question previous assumptions concerning the quality of life among people with Alzheimer's, and to address the question: does the concept of palliative care properly embrace people with severe dementia? We propose an ethic of palliative care for people with Alzheimer's that is based, not on the traditionally understood principle of autonomy, but on the need to listen to those living with the disease, acknowledging their profound loss of cognitive abilities, with a focus on preventing and relieving suffering, and improving the individual's quality of life.

What determines referral of UK patients with haematological malignancies to palliative care services? An exploratory study using hospital records

We investigated the frequency and characteristics of patients with haematological malignancies (HMs) who were, or were not, referred for specialist palliative care (SPC). Data were abstracted from hospital records of 108 patients who died - 27 with leukaemia, 11 with myelodysplastic syndromes, 48 with lymphoma and 22 with myeloma. Ninety-three patients (86.1%) were >60 years of age at diagnosis, with 33 (30.6%) being >or=80 years and 31 (28.7%) having existing comorbidities. Thirty-three patients (30.6%) were referred to SPC services. There was little difference by age or HM diagnosis in referred patients. Seventeen of 67 patients (25.4%) dying on a hospital ward received SPC compared with 6/7 (85.7%) dying at home. Time between diagnosis and death influenced the referral - 24/52 patients (46.2%) dying >or=30 days after diagnosis received SPC compared with 8/42 (19.1%) dying within 30 days. In 14 patients, HM diagnosis was confirmed after death. Identification of these 14 patients is likely to be a unique feature of our study, as patients were selected from a regional, population-based register with centralized diagnostic services, enabling the identification of all patients with HM. The interface between curative and palliative treatment in HM is more complex than the National Institute for Clinical Excellence recommendations suggest.

Old people receiving municipal care, their experiences of what constitutes a good life in the last phase of life: a qualitative study

BACKGROUND

Old people's life situation when receiving municipal help and care in their last period of life is sparsely investigated from their own perspective.

OBJECTIVE

The aim of this study was to investigate the experiences of aspects that bring about a good life in the last phase of life among people (75+ years) receiving municipal care.

PARTICIPANTS

Older people living in a municipality in Southern Sweden being 75 years or older, receiving help and/or care from the municipality, and having a life-threatening disease and/or receiving palliative care were asked to participate. In all 17 people, 10 women and 7 men, aged 78-100 years were included.

METHODS

Qualitative interviews, with the emphasis on their present life situation especially what brought about a good life, were performed. The interviews were analysed using qualitative content analysis.

RESULTS

The experience was interpreted to be Turning inwards to come to peace with the past, the present and approaching death while being trapped by health complaints. Six categories embraced the experience of aspects that constitute a good life in the last phase of life: Maintaining dignity, Enjoying small things, Feelings of "being at home", Being in the hands of others, trying to adjust, Still being important for other people and Completing life while facing death.

CONCLUSION

This study confirm theories suggesting that the last phase of life in old age meant focusing inwards, reflecting on the entire life as a way of completing it as well as enjoying small things and also viewing oneself in the perspective of contributing to the future. It also indicated that this phase of life meant being trapped by health complaints and functional limitations. The struggle to maintaining dignity as opposed to being in the hands of others implies that the concept of palliative care may be useful as a framework for providing nursing care to very old people, especially at the end of life.