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Sawatzky R, Porterfield P, Donald E, Tayler C, Stajduhar K, Thorne S. Voices lost: where is the person in evaluating a palliative approach to care? Palliat Care Soc Pract 2023; 17:26323524231193041. [PMID: 37654732 PMCID: PMC10467210 DOI: 10.1177/26323524231193041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Person-centredness is a cornerstone to a palliative approach to care. However, there is a risk that a person-centred perspective is lost in how a palliative approach is evaluated. We explored the extent to which evaluations of a palliative approach are consistent with its person-centred ethical stance. Using a narrative review approach, we critically reflected on how the experiences, priorities and concerns of patients and family are represented, or not represented, in evaluations of a palliative approach. We were guided by the following questions: (1) What types of outcomes and indicators are commonly used to evaluate a palliative approach? (2) Whose perspectives are represented in current evaluations of a palliative approach? And (3) What are the foci of evaluation in this body of research? We observed that the evaluations of a palliative approach are commonly based on indicators of its implementation and predominantly reflect the perspectives of healthcare providers and healthcare systems, rather than patients or family. Although evaluations focused on healthcare providers and systems are important for integrating a palliative approach, there is concern that the essence of person-centredness is lost when the perspectives of patients and families about their healthcare needs, outcomes and experiences are not consistently measured as the ultimate goal of care. There is a need for more emphasis on evaluation practices that value person-centred outcomes, in addition to outcomes oriented to the needs of healthcare providers and systems.
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Affiliation(s)
- Richard Sawatzky
- School of Nursing, Trinity Western University, 22500 University Drive, Langley, BC, V2Y 1Y1, Canada
- Centre for Advancing Health Outcomes Sciences, Vancouver, BC, Canada
| | | | - Erin Donald
- School of Nursing & Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Carolyn Tayler
- British Columbia Centre for Palliative Care, Vancouver, BC, Canada
| | - Kelli Stajduhar
- School of Nursing & Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
| | - Sally Thorne
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study. Palliat Support Care 2021; 20:637-645. [DOI: 10.1017/s1478951521001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objective
Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.
Method
Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.
Results
Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.
Significance of results
Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.
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Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis. Br J Gen Pract 2021; 71:e780-e787. [PMID: 34489250 PMCID: PMC8436777 DOI: 10.3399/bjgp.2021.0194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/11/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Out-of-hours (OOH) hospital admissions for patients receiving end-of-life care are a common cause of concern for patients, families, clinicians, and policymakers. It is unclear what issues, or combinations of issues, lead OOH clinicians to initiate hospital care for these patients. AIM To investigate the circumstances, processes, and mechanisms of UK OOH services-initiated end-of-life care hospital admissions. DESIGN AND SETTING Systematic literature review and narrative synthesis. METHOD Eight electronic databases were searched from inception to December 2019 supplemented by hand-searching of the British Journal of General Practice. Key search terms included: 'out-of-hours services', 'hospital admissions', and 'end-of-life care'. Two reviewers independently screened and selected articles, and undertook quality appraisal using Gough's Weight of Evidence framework. Data was analysed using narrative synthesis and reported following PRISMA Complex Intervention guidance. RESULTS Searches identified 20 727 unique citations, 25 of which met the inclusion criteria. Few studies had a primary focus on the review questions. Admissions were instigated primarily to address clinical needs, caregiver and/or patient distress, and discontinuity or unavailability of care provision, and they were arranged by a range of OOH providers. Reported frequencies of patients receiving end-of-life care being admitted to hospital varied greatly; most evidence related to cancer patients. CONCLUSION Although OOH end-of-life care can often be readily resolved by hospital admissions, it comes with multiple challenges that seem to be widespread and systemic. Further research is therefore necessary to understand the complexities of OOH services-initiated end-of-life care hospital admissions and how the challenges underpinning such admissions might best be addressed.
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Strupp J, Kasdorf A, Dust G, Hower KI, Seibert M, Werner B, Kuntz L, Schulz-Nieswandt F, Meyer I, Pfaff H, Hellmich M, Voltz R. Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care. BMJ Open 2021; 11:e048681. [PMID: 34312205 PMCID: PMC8314737 DOI: 10.1136/bmjopen-2021-048681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The Last Year of Life Study-Cologne Part I (LYOL-C I) has identified general hospital units as the most important checkpoints for transitions in the last year of life of patients. Yet, satisfaction with hospitals, as reported by bereaved relatives, is the lowest of all health service providers. Thus, the LYOL-C Part II (LYOL-C II) focuses on optimising patient-centred care in acute hospitals for patients identified to be in their last year of life. LYOL-C II aims to test an intervention for hospitals by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner. METHODS AND ANALYSIS Prospective interventional mixed-methods study following a two-phase approach: phase I, individual interviews with HCPs and patient representatives to design the intervention to maximise ease of implementation and phase II, exploratory study with two arms and a prepost design with patients in their last year of life. The intervention will consist of the Surprise Question and the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for HCPs to identify patients and provide patient-centred care, plus question prompt sheets for patients, encouraging them to initiate discussions with their HCPs. Data on transitions, changes in therapy, quality of care, palliative care integration and death of patients will be analysed. Furthermore, a staff survey (pre/post) and guided interviews with staff, patients and relatives (post) will be conducted. Finally, a formative socioeconomic impact assessment to provide evidence regarding the sustainability of the intervention will be performed. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Cologne (#20-1431). Results will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER DRKS00022378.
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Affiliation(s)
- Julia Strupp
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Alina Kasdorf
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Gloria Dust
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Kira Isabel Hower
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Melissa Seibert
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Belinda Werner
- Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Frank Schulz-Nieswandt
- Faculty of Management, Economics and Social Sciences, University of Cologne, Cologne, Germany
| | - Ingo Meyer
- PMV Research Group, Department of Child and Adolescence Psychiatry, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Kasdorf A, Dust G, Vennedey V, Rietz C, Polidori MC, Voltz R, Strupp J. What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals' perspectives for improving care in Germany. BMC Health Serv Res 2021; 21:147. [PMID: 33588851 PMCID: PMC7885553 DOI: 10.1186/s12913-021-06138-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/31/2021] [Indexed: 11/18/2022] Open
Abstract
Background Little is known about the nature of patients’ transitions between healthcare settings in the last year of life (LYOL) in Germany. Patients often experience transitions between different healthcare settings, such as hospitals and long-term facilities including nursing homes and hospices. The perspective of healthcare professionals can therefore provide information on transitions in the LYOL that are avoidable from a medical perspective. This study aims to explore factors influencing avoidable transitions across healthcare settings in the LYOL and to disclose how these could be prevented. Methods Two focus groups (n = 11) and five individual interviews were conducted with healthcare professionals working in hospitals, hospices and nursing services from Cologne, Germany. They were asked to share their observations about avoidable transitions in the LYOL. The data collection continued until the point of information power was reached and were audio recorded and analysed using qualitative content analysis. Results Four factors for potentially avoidable transitions between care settings in the LYOL were identified: healthcare system, organization, healthcare professional, patient and relatives. According to the participants, the most relevant aspects that can aid in reducing unnecessary transitions include timely identification and communication of the LYOL; consideration of palliative care options; availability and accessibility of care services; and having a healthcare professional taking main responsibility for care planning. Conclusions Preventing avoidable transitions by considering the multicomponent factors related to them not only immediately before death but also in the LYOL could help to provide more value-based care for patients and improving their quality of life. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06138-4.
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Affiliation(s)
- Alina Kasdorf
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.
| | - Gloria Dust
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Christian Rietz
- Department of Educational Science and Mixed-Methods-Research, University of Education Heidelberg, Faculty of Educational and Social Sciences, Heidelberg, Germany
| | - Maria C Polidori
- Department II of Internal Medicine and Cologne Center for Molecular Medicine, Ageing Clinical Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Cluster of Excellence CECAD, University of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Clinical Trials Center (ZKS), University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany.,Center for Health Services Research, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
| | - Julia Strupp
- Department of Palliative Medicine, University of Cologne, Faculty of Medicine and University Hospital, Cologne, Germany
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Hopkins SA, Bentley A, Phillips V, Barclay S. Advance care plans and hospitalized frail older adults: a systematic review. BMJ Support Palliat Care 2020; 10:164-174. [PMID: 32241957 PMCID: PMC7286036 DOI: 10.1136/bmjspcare-2019-002093] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/27/2020] [Accepted: 02/10/2020] [Indexed: 12/28/2022]
Abstract
Introduction Frail older people are known to have low rates of advance care planning (ACP). Many frail patients prefer less aggressive treatment, but these preferences are often not known or respected. Frail patients often have multiple hospital admissions, potentially providing opportunities for ACP. Objective To systematically review the literature concerning ACP with frail older people in the acute hospital, with particular reference to: (1) Does ACP improve outcomes? (2) What are the views of patients, relatives and healthcare professionals regarding ACP? (3) Does ACP currently occur? (4) What are the facilitators and barriers to ACP? Design Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO and Embase databases from January 1990 to May 2019 inclusive. Studies in the acute setting of populations with a mean age >75 years, not focused on a disease-specific terminal condition were included. Results 16 133 articles were retrieved, 14 met inclusion criteria. No studies used an objective measure of frailty. One randomised controlled trial (RCT) found that ACP improves outcomes for older patients. Although 74%–84% of capacitous older inpatients are receptive to ACP, rates of ACP are 0%–5%; the reasons for this discrepancy have been little studied. The nature of ACP in clinical practice is unknown thus the extent to which it reflects the RCT intervention cannot be assessed. The outcomes that are important to patients are poorly understood and family and physician experiences have not been explored. Conclusions A better understanding of this area could help to improve end-of-life care for frail older people. PROSPERO registration number CRD42017080246.
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Affiliation(s)
- Sarah A Hopkins
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Allison Bentley
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Abstract
Most people die when they are old, with multiple pathologies, and while living with frailty or dementia. These circumstances need the specialist skills of geriatric medicine. Death may not be unexpected, but survival and restoration of function are usually uncertain, influencing the approach to medical intervention. Assessment considers medical, functional, mental, social and environmental domains. Care requires a mix of acute, rehabilitation, mental health and palliative expertise, and evolves with changing circumstances. Relief of suffering and maintenance of function are key goals, but not the only ones. Mental distress is as common as physical; investigation- and treatment-burden are important; drug treatments are prone to adverse effects. A focus on person-centredness rather than the end-of-life is needed. This prioritizes respect for individual diversity in needs, assets and priorities, and rigorous decision making, to achieve what is the right intervention for that person at that time.
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Affiliation(s)
- Hannah Enguell
- Academic Clinical Fellow, Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham
| | - Rowan H Harwood
- Professor of Palliative and End-of-Life Care and Honorary Consultant Geriatrician, School of Health Sciences, University of Nottingham, Nottingham NG7 2UH
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Chambers E, Gardiner C, Thompson J, Seymour J. Patient and carer involvement in palliative care research: An integrative qualitative evidence synthesis review. Palliat Med 2019; 33:969-984. [PMID: 31250702 PMCID: PMC6691598 DOI: 10.1177/0269216319858247] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patient/carer involvement in palliative care research has been reported as complex, difficult and less advanced compared to other areas of health and social care research. There is seemingly limited evidence on impact and effectiveness. AIM To examine the evidence regarding patient/carer involvement in palliative care research and identify the facilitators, barriers, impacts and gaps in the evidence base. DESIGN Qualitative evidence synthesis using an integrative review approach and thematic analysis. DATA SOURCES Electronic databases were searched up to March 2018. Additional methods included searching websites and ongoing/unpublished studies, author searching and contacting experts. Eligibility criteria were based on the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) framework. Two quality assessments on methodology and involvement were undertaken. RESULTS A total of 93 records were included. Eight main themes were identified, mainly concerning facilitators and barriers to effective patient and carer involvement in palliative care research: definitions/roles, values/principles, organisations/culture, training/support, networking/groups, perspectives/diversity, relationships/communication and emotions/impact. Evidence on the impact of involvement was limited, but when carried out effectively, involvement brought positive benefits for all concerned, improving the relevance and quality of research. Evidence gaps were found in non-cancer populations and collaborative/user-led involvement. CONCLUSION Evidence identified suggests that involvement in palliative care research is challenging, but not dissimilar to that elsewhere. The facilitators and barriers identified relate mainly to the conduct of researchers at an individual level; in particular, there exists a reluctance among professionals to undertake involvement, and myths still perpetuate that patients/carers do not want to be involved. A developed infrastructure, more involvement-friendly organisational cultures and a strengthening of the evidence base would also be beneficial.
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Affiliation(s)
- Eleni Chambers
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Clare Gardiner
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Jill Thompson
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Jane Seymour
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
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Damani A, Ghoshal A, Dighe M, Dhiliwal S, Muckaden M. Exploring Education and Training Needs in Palliative Care among Family Physicians in Mumbai: A Qualitative Study. Indian J Palliat Care 2018; 24:139-144. [PMID: 29736114 PMCID: PMC5915878 DOI: 10.4103/ijpc.ijpc_216_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Context: Patients with chronic life-limiting conditions on palliative care (PC) prefer to be treated at home. Medical care by family physicians (FPs) reduces demand on costly and busy hospital facilities. Working of PC team in collaboration with FPs is thus helpful in home-based management of patients. Aims: This study aimed at exploring the extent of knowledge of FPs about PC and the need for additional training. Settings and Design: Semi-structured interviews were conducted with ten FPs from two suburbs of Mumbai, currently served by home care services of a tertiary cancer care center. Subjects and Methods: Data were digitally recorded, transcribed, and analyzed using exploratory analysis followed by content analysis to develop thematic codes. Results and Conclusions: FPs perceive PC as symptom control and psychological support helpful in managing patients with advanced life-limiting illnesses. Further training would help them in PC provision. Such training programs should preferably focus on symptom management and communication skills. There is a need for further research in designing a training module for FPs to get better understanding of the principles of PC.
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Affiliation(s)
- Anuja Damani
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Manjiri Dighe
- Cipla Palliative Care and Training Centre, Pune, Maharashtra, India
| | - Sunil Dhiliwal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
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Fleming J, Calloway R, Perrels A, Farquhar M, Barclay S, Brayne C. Dying comfortably in very old age with or without dementia in different care settings - a representative "older old" population study. BMC Geriatr 2017; 17:222. [PMID: 28978301 PMCID: PMC5628473 DOI: 10.1186/s12877-017-0605-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/01/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Comfort is frequently ranked important for a good death. Although rising numbers of people are dying in very old age, many with dementia, little is known about symptom control for "older old" people or whether care in different settings enables them to die comfortably. This study aims to examine, in a population-representative sample, associations between factors potentially related to reported comfort during very old people's final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. METHODS Retrospective analyses linked three data sources for n = 180 deceased study participants (68% women) aged 79-107 in a representative population-based UK study, the Cambridge City over-75s Cohort (CC75C): i) prospective in-vivo dementia diagnoses and cognitive assessments, ii) certified place of death records, iii) data from interviews with relatives/close carers including symptoms and "How comfortable was he/she in his/her final illness?" RESULTS In the last year of life 83% were disabled in basic activities, 37% had moderate/severe dementia and 45% minimal/mild dementia or cognitive impairment. Regardless of dementia/cognitive status, three-quarters died following a final illness lasting a week or longer. 37%, 44%, 13% and 7% of the deceased were described as having been "very comfortable", "comfortable", "fairly comfortable" or "uncomfortable" respectively during their final illness, but reported symptoms were common: distress, pain, depression and delirium or confusion each affected 40-50%. For only 10% were no symptoms reported. There were ≥4-fold increased odds of dying comfortably associated with being in a care home during the final illness, dying in a care home, and with staying in place (dying at what death certificates record as "usual address"), whether home or care home, compared with hospital, but no significant association with disability or dementia/cognitive status, regardless of adjustment. CONCLUSIONS These findings are consistent with reports that care homes can provide care akin to hospice for the very old and support an approach of supporting residents to stay in their care home or own home if possible. Findings on reported high prevalence of multiple symptoms can inform policy and training to improve older old people's end-of-life care in all settings.
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Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Rowan Calloway
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- North East Thames Foundation School, London, UK
| | - Anouk Perrels
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Faculty of Medicine, Vrije Universiteit, Amsterdam, Netherlands
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
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Lazenby S, Edwards A, Samuriwo R, Riley S, Murray MA, Carson‐Stevens A. End-of-life care decisions for haemodialysis patients - 'We only tend to have that discussion with them when they start deteriorating'. Health Expect 2017; 20:260-273. [PMID: 26968338 PMCID: PMC5354044 DOI: 10.1111/hex.12454] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Haemodialysis patients receive very little involvement in their end-of-life care decisions. Issues relating to death and dying are commonly avoided until late in their illness. This study aimed to explore the experiences and perceptions of doctors and nurses in nephrology for involving haemodialysis patients in end-of-life care decisions. METHODS A semi-structured qualitative interview study with 15 doctors and five nurses and thematic analysis of their accounts was conducted. The setting was a large teaching hospital in Wales, UK. RESULTS Prognosis is not routinely discussed with patients, in part due to a difficulty in estimation and the belief that patients do not want or need this information. Advance care planning is rarely carried out, and end-of-life care discussions are seldom initiated prior to patient deterioration. There is variability in end-of-life practices amongst nephrologists; some patients are felt to be withdrawn from dialysis too late. Furthermore, the possibility and implications of withdrawal are not commonly discussed with well patients. Critical barriers hindering better end-of-life care involvement for these patients are outlined. CONCLUSIONS The study provides insights into the complexity of end-of-life conversations and the barriers to achieving better end-of-life communication practices. The results identify opportunities for improving the lives and deaths of haemodialysis patients.
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Affiliation(s)
- Sophia Lazenby
- Primary Care Patient Safety (PISA) Research GroupDivision of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Adrian Edwards
- Division of Population MedicineSchool of MedicineCardiff UniversityCardiffWalesUK
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
| | - Raymond Samuriwo
- School of Healthcare SciencesCardiff UniversityCardiffWalesUK
- Cardiff Institute for Tissue Engineering and RepairCardiff UniversityCardiffWalesUK
- School of HealthcareUniversity of LeedsLeedsUK
| | | | - Mary Ann Murray
- Nursing Palliative Research and Education UnitFaculty of Health SciencesUniversity of OttawaOttawaONCanada
| | - Andrew Carson‐Stevens
- Primary and Emergency Care Research (PRIME) Centre WalesCardiff UniversityCardiffWalesUK
- Department of Family PracticeUniversity of British ColumbiaVancouverBCCanada
- Institute of Healthcare Policy and PracticeUniversity of the West of ScotlandPaisleyScotland
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12
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Nicholson C, Morrow EM, Hicks A, Fitzpatrick J. Supportive care for older people with frailty in hospital: An integrative review. Int J Nurs Stud 2016; 66:60-71. [PMID: 28012311 DOI: 10.1016/j.ijnurstu.2016.11.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Growing numbers of older people living with frailty and chronic health conditions are being referred to hospitals with acute care needs. Supportive care is a potentially highly relevant and clinically important approach which could bridge the practice gap between curative models of care and palliative care. However, future interventions need to be informed and underpinned by existing knowledge of supportive care. AIM To identify and build upon existing theories and evidence about supportive care, specifically in relation to the hospital care of older people with frailty, to inform future interventions and their evaluation. DESIGN An integrative review was used to identify and integrate theory and evidence. Electronic databases (Cochrane Medline, EMBASE and CIHAHL) were searched using the key term 'supportive care'. Screening identified studies employing qualitative and/or quantitative methods published between January 1990 and December 2015. Citation searches, reference checking and searches of the grey literature were also undertaken. DATA SOURCES Literature searches identified 2733 articles. After screening, and applying eligibility criteria based on relevance to the research question, studies were subject to methodological quality appraisal. Findings from included articles (n=52) were integrated using synthesis of themes. RESULTS Relevant evidence was identified across different research literatures, on clinical conditions and contexts. Seven distinct themes of the synthesis were identified, these were: Ensuring fundamental aspects of care are met, Communicating and connecting with the patient, Carer and family engagement, Building up a picture of the person and their circumstances, Decisions and advice about best care for the person, Enabling self-help and connection to wider support, and Supporting patients through transitions in care. A tentative integrative model of supportive care for frail older people is developed from the findings. CONCLUSION The findings and model developed here will inform future interventions and can help staff and hospital managers to develop appropriate strategies, staff training and resource allocation models to improve the quality of health care for older people.
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Affiliation(s)
- Caroline Nicholson
- Supportive and End of Life Care (Nursing), King's College London/St. Christopher's Hospice, King's College London, Florence Nightingale Faculty of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Elizabeth M Morrow
- Research Support, Northern Ireland, Belfast, Northern Ireland BT30 9QT, United Kingdom.
| | - Allan Hicks
- City University of London, School of Health Sciences, United Kingdom
| | - Joanne Fitzpatrick
- King's College London, Florence Nightingale Faculty of Nursing and Midwifery, United Kingdom
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13
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Fleming J, Farquhar M, Brayne C, Barclay S. Death and the Oldest Old: Attitudes and Preferences for End-of-Life Care--Qualitative Research within a Population-Based Cohort Study. PLoS One 2016; 11:e0150686. [PMID: 27045734 PMCID: PMC4821585 DOI: 10.1371/journal.pone.0150686] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/18/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Increasing longevity means more people will be dying in very old age, but little is known about the preferences of the 'oldest old' regarding their care at the end of life. AIMS To understand very old people's preferences regarding care towards the end of life and attitudes towards dying, to inform policy and practice. METHODS Qualitative data collection for n = 42 population-based cohort study participants aged 95-101 (88% women, 42% in long-term-care): topic-guided interviews with n = 33 participants and n = 39 proxy informants, most with both (n = 30: 4 jointly + separate interviews for 26 dyads). RESULTS Death was a part of life: these very old people mainly live day-to-day. Most were ready to die, reflecting their concerns regarding quality of life, being a nuisance, having nothing to live for and having lived long enough. Contrasting views were rare exceptions but voiced firmly. Most were not worried about death itself, but concerned more about the dying process and impacts on those left behind; a peaceful and pain-free death was a common ideal. Attitudes ranged from not wanting to think about death, through accepting its inevitable approach to longing for its release. Preferring to be made comfortable rather than have life-saving treatment if seriously ill, and wishing to avoid hospital, were commonly expressed views. There was little or no future planning, some consciously choosing not to. Uncertainty hampered end-of-life planning even when death was expected soon. Some stressed circumstances, such as severe dependency and others' likely decision-making roles, would influence choices. Carers found these issues harder to raise but felt they would know their older relatives' preferences, usually palliative care, although we found two discrepant views. CONCLUSIONS This study's rare data show ≥95-year-olds are willing to discuss dying and end-of-life care but seldom do. Formal documentation of wishes is extremely rare and may not be welcome. Although being "ready to die" and preferring a palliative approach predominated, these preferences cannot be assumed.
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Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Morag Farquhar
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | | | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
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14
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Gott M, Moeke-Maxwell T, Williams L, Black S, Trussardi G, Wiles J, Mules R, Rolleston A, Kerse N. Te Pākeketanga: living and dying in advanced age--a study protocol. BMC Palliat Care 2015; 14:74. [PMID: 26691519 PMCID: PMC4687083 DOI: 10.1186/s12904-015-0073-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of people dying in advanced old age is increasing rapidly and building the evidence base regarding end - of - life care for older people has been identified as an international policy priority. The unique opportunity to link longitudinal studies of ageing with studies exploring the end of life circumstances of older people remains under-exploited internationally. Very little is known about the specific circumstances, cultural needs and care preferences of indigenous older people, including Māori, at end - of - life and the needs of their whānau/ extended family carers. METHODS We will use rigorous qualitative methods to conduct post-bereavement interviews with bereaved whānau and family of 50-60 people who died >80 years; approximately half of participants will be Maori. The older decedents were participants in the first longitudinal study of older people involving a specific indigenous cohort internationally: Te Puāwaitanga O Ngā Tapuwae Kia Ora Tonu, Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ). Prior to death, they completed a questionnaire regarding their end-of-life preferences and nominated a family or whānau member to participate in this separate study exploring end-of-life circumstances of those in advanced age. DISCUSSION Recommendations to improve care will be formulated in collaboration with participants and their local hapū (sub-tribe). Ultimately this study has the potential to inform better outcomes for the growing numbers of people dying in advanced old age both in New Zealand and internationally, as well as their whānau and family caregivers. It also highlights the ability to generate an in-depth understanding of end-of-life circumstances by appending studies of palliative and end-of-life care onto existing longitudinal studies.
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Affiliation(s)
- Merryn Gott
- School of Nursing, University of Auckland, Boyle Building, 85 Park Road, Auckland, New Zealand.
| | - Tess Moeke-Maxwell
- School of Nursing, University of Auckland, Boyle Building, 85 Park Road, Auckland, New Zealand
| | - Lisa Williams
- School of Nursing, University of Auckland, Boyle Building, 85 Park Road, Auckland, New Zealand
| | - Stella Black
- School of Nursing, University of Auckland, Boyle Building, 85 Park Road, Auckland, New Zealand
| | - Gabriella Trussardi
- School of Nursing, University of Auckland, Boyle Building, 85 Park Road, Auckland, New Zealand
| | - Janine Wiles
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Rangimarie Mules
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Anna Rolleston
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Ngaire Kerse
- School of Population Health, University of Auckland, Auckland, New Zealand
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15
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Research roundup. Int J Palliat Nurs 2013. [DOI: 10.12968/ijpn.2013.19.12.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
These pages provide brief synopses of a selection of recently published research articles of relevance to palliative care.
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