Do family meetings for hospitalised palliative care patients improve outcomes and reduce health care costs? A cluster randomised trial

BACKGROUND

Family meetings facilitate the exploration of issues and goals of care however, there has been minimal research to determine the benefits and cost implications.

AIMS

To determine: (1) if family caregivers of hospitalised patients referred to palliative care who receive a structured family meeting report lower psychological distress (primary outcome), fewer unmet needs, improved quality of life; feel more prepared for the caregiving role; and receive better quality of end-of-life care; (2) if outcomes vary dependant upon site of care and; (3) the cost-benefit of implementing meetings into routine practice.

DESIGN

Pragmatic cluster randomised trial involving palliative care patients and their primary family caregivers at three Australian hospitals. Participants completed measures upon admission (Time 1); 10 days later (Time 2) and two months after the patient died (Time 3). Regression analyses, health utilisation and process evaluation were conducted.

RESULTS

297 dyads recruited; control (n = 153) and intervention (n = 144). The intervention group demonstrated significantly lower psychological distress (Diff: -1.68, p < 0.01) and higher preparedness (Diff: 3.48, p = 0.001) at Time 2. No differences were identified based on quality of end of life care or health utilisation measures.

CONCLUSIONS

Family meetings may be helpful in reducing family caregiver distress and enhancing their preparedness for the caregiving role and it appears they may be conducted without increased hospital health utilisation impacts; although opportunity costs need to be considered in order to routinely offer these as a standardised intervention. Additional health economic examination is also advocated to comprehensively understand the cost-benefit implications.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12615000200583.

Sequences of talk about emotional concerns in follow-up consultations with adolescent childhood cancer survivors

OBJECTIVE

To explore practices regarding communication about emotional concerns in follow-up consultations with adolescent cancer survivors and pediatrician.

METHOD

Seven video-taped follow-up consultations with adolescent survivors which contained many examples of emotional cues and concern were analyzed according to principles of conversation analysis.

RESULTS

During talk about emotional concerns, a task-focused asymmetric pattern of pediatrician questions and patient responses was most often upheld. In a number of cases a gradual build-up of emotional expression from a weak hint to a more explicit expression of emotional concern was observed, often facilitated by the pediatricians. Most often work-up was relatively brief, sometimes with a brief positive reappraisal, but more comprehensive elaboration was also seen. Topic shifts were often abrupt.

CONCLUSION

Pediatricians and patients used some of the same conventions as in everyday conversation during emotional talk in medical encounters. We observed shifts between informal talk and a typical task-focused mode. Conscious attention to such shifts and to the sequential nature of emotional talk could be helpful for doctors in designing their responses to patients' emotional concerns.

PRACTICE IMPLICATIONS

Our findings may contribute to insight in how clinicians respond to emotional concerns in follow-up consultations and have implications for communication skills training.

Benefits and resource implications of family meetings for hospitalized palliative care patients: research protocol

BACKGROUND

Palliative care focuses on supporting patients diagnosed with advanced, incurable disease; it is 'family centered', with the patient and their family (the unit of care) being core to all its endeavours. However, approximately 30-50% of carers experience psychological distress which is typically under recognised and consequently not addressed. Family meetings (FM) are recommended as a means whereby health professionals, together with family carers and patients discuss psychosocial issues and plan care; however there is minimal empirical research to determine the net effect of these meetings and the resources required to implement them systematically. The aims of this study were to evaluate: (1) if family carers of hospitalised patients with advanced disease (referred to a specialist palliative care in-patient setting or palliative care consultancy service) who receive a FM report significantly lower psychological distress (primary outcome), fewer unmet needs, increased quality of life and feel more prepared for the caregiving role; (2) if patients who receive the FM experience appropriate quality of end-of-life care, as demonstrated by fewer hospital admissions, fewer emergency department presentations, fewer intensive care unit hours, less chemotherapy treatment (in last 30 days of life), and higher likelihood of death in the place of their choice and access to supportive care services; (3) the optimal time point to deliver FM and; (4) to determine the cost-benefit and resource implications of implementing FM meetings into routine practice.

METHODS

Cluster type trial design with two way randomization for aims 1-3 and health economic modeling and qualitative interviews with health for professionals for aim 4.

DISCUSSION

The research will determine whether FMs have positive practical and psychological impacts on the family, impacts on health service usage, and financial benefits to the health care sector. This study will also provide clear guidance on appropriate timing in the disease/care trajectory to provide a family meeting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000200583.

Communicative practices in talking about death and dying in the context of Thai cancer care

This article explores communicative practices surrounding how nurses, patients and family members engage when talking about death and dying, based on study conducted in a province in northern Thailand. Data were collected from three environments: a district hospital (nine cases), district public health centres (four cases), and in patients' homes (27 cases). Fourteen nurses, 40 patients and 24 family members gave written consent for participation. Direct observation and in-depth interviews were used for supplementary data collection, and 40 counselling sessions were recorded on video. The raw data were analysed using Conversation Analysis. The study found that Thai counselling is asymmetrical. Nurses initiated the topic of death by referring to the death of a third person--a dead patient--with the use of clues and via list-construction. As most Thai people are oriented to Buddhism, religious support is selected for discussing this sensitive topic, and nurses also use Buddhism and list-construction to help their clients confront uncertain futures. However, Buddhism is not brought into discussion on its own, but combined with other techniques such as the use of euphemisms or concern and care for others.