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Mitchell S, Turner N, Fryer K, Aunger J, Beng J, Couchman E, Leach I, Bayly J, Gardiner C, Sleeman KE, Evans CJ. Integration of primary care and palliative care services to improve equality and equity at the end-of-life: Findings from realist stakeholder workshops. Palliat Med 2024:2692163241248962. [PMID: 38733139 DOI: 10.1177/02692163241248962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND Inequalities in access to palliative and end of life care are longstanding. Integration of primary and palliative care has the potential to improve equity in the community. Evidence to inform integration is scarce as research that considers integration of primary care and palliative care services is rare. AIM To address the questions: 'how can inequalities in access to community palliative and end of life care be improved through the integration of primary and palliative care, and what are the benefits?' DESIGN A theory-driven realist inquiry with two stakeholder workshops to explore how, when and why inequalities can be improved through integration. Realist analysis leading to explanatory context(c)-mechanism(m)-outcome(o) configurations(c) (CMOCs). FINDINGS A total of 27 participants attended online workshops (July and September 2022): patient and public members (n = 6), commissioners (n = 2), primary care (n = 5) and specialist palliative care professionals (n = 14). Most were White British (n = 22), other ethnicities were Asian (n = 3), Black African (n = 1) and British mixed race (n = 1). Power imbalances and racism hinder people from ethnic minority backgrounds accessing current services. Shared commitment to addressing these across palliative care and primary care is required in integrated partnerships. Partnership functioning depends on trusted relationships and effective communication, enabled by co-location and record sharing. Positive patient experiences provide affirmation for the multi-disciplinary team, grow confidence and drive improvements. CONCLUSIONS Integration to address inequalities needs recognition of current barriers. Integration grounded in trust, faith and confidence can lead to a cycle of positive patient, carer and professional experience. Prioritising inequalities as whole system concern is required for future service delivery and research.
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Affiliation(s)
- Sarah Mitchell
- Division of Primary Care, Palliative Care and Public Health, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Nicola Turner
- University of Nottingham School of Health Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Kate Fryer
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Justin Aunger
- NIHR Midlands Patient Safety Research Collaboration, Murray Learning Centre, University of Birmingham, Birmingham, UK
| | - Jude Beng
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Emilie Couchman
- Health Sciences School, University of Sheffield, Sheffield, UK
| | - Isabel Leach
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Joanne Bayly
- St Barnabas Hospices, Worthing, UK
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, London, UK
| | - Clare Gardiner
- Health Sciences School, University of Sheffield, Sheffield, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, London, UK
- Sussex Community NHS Foundation Trust, Crawley, UK
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Dodson S. Exploring whether a diagnosis of severe frailty prompts advance care planning and end of life care conversations. Nurs Older People 2024:e1459. [PMID: 38379374 DOI: 10.7748/nop.2024.e1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND Older people with frailty are susceptible to sudden and rapid deterioration, so discussing their wishes and preferences for care at the end of life should be a priority. However, frailty is often not considered or recognised, which impedes patient-centred decision-making. AIM To explore the views and perceptions of senior healthcare professionals regarding the usefulness of the Clinical Frailty Scale (CFS) in identifying frailty; whether a CFS score of severe frailty leads senior healthcare professionals to recognise that the person is likely to be approaching the end of life; and whether a CFS score of severe frailty prompts senior healthcare professionals to have conversations about advance care planning and end of life care with patients. METHOD Semi-structured individual interviews were undertaken with seven senior healthcare professionals at one hospital in England. Data were analysed using thematic analysis. FINDINGS Frailty appeared to be complex, multifaceted and at times difficult to identify. A diagnosis of severe frailty did not necessarily prompt advance care planning and end of life care conversations. Such conversations were more likely to happen if the person had comorbidities, for example cancer. Prognostication appeared to be challenging, partly due to the gradual and uncertain trajectory in frailty and a lack of understanding, on the part of healthcare professionals, of the condition and its effects. CONCLUSION People with severe frailty may be disadvantaged in terms of receiving appropriate end of life care. Better education on frailty for all healthcare professionals would facilitate conversations about advance care planning and end of life care with patients diagnosed with severe frailty.
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Affiliation(s)
- Stacey Dodson
- Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, England
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3
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Polak L, Etkind S. Who 'needs' community palliative care? Prognosis-centred registers disadvantage frail older people. Br J Gen Pract 2024; 74:56-57. [PMID: 38272694 PMCID: PMC10824355 DOI: 10.3399/bjgp24x736161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Affiliation(s)
- Louisa Polak
- Primary Care Unit, University of Cambridge, Cambridge
| | - Simon Etkind
- Primary Care Unit, University of Cambridge, Cambridge
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4
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Polak L. Palliative care in dementia: referring to "end of life" is unnecessary. BMJ 2023; 381:p1262. [PMID: 37286213 DOI: 10.1136/bmj.p1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Louisa Polak
- Palliative and End-of-Life Research Team, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
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5
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While A. Assuring good deaths at home. Br J Community Nurs 2022; 27:150. [PMID: 35274976 DOI: 10.12968/bjcn.2022.27.3.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alison While
- Emeritus Professor of Community Nursing, Florence Nightingale Faculty of Nursing, King's College London and Midwifery and Fellow of the Queen's Nursing Institute
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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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