Dying, death and bereavement: developing a national survey of bereaved relatives

BACKGROUND

Assessing and measuring the experience and quality of care provided is central to the improvement of care delivery of all healthcare systems. This paper reports on the development of a survey instrument to capture the experiences of care at end of life from the perspective of bereaved relatives in the Republic of Ireland.

METHODS

A multi-method, multi-stakeholder, sequential approach was adopted for this study. Items for inclusion in the survey instrument bank were identified through (1) a feasibility study and scoping literature review, (2) expert panel programme board review, (3) focus groups and (4) gap analysis. The following steps were undertaken to prioritise the items for inclusion in the final survey instrument: (1) a Delphi study (2) technical expert panel review (3) cognitive interviews with bereaved relatives and an (4) expert panel programme board review.

RESULTS

Following an iterative process with key stakeholders, a survey instrument was developed with sections focusing on the provision of care at home, in the last nursing home / residential care facility, hospice and hospital, as well as care experience in the last 2 days of life, the relative's experiences of care and support, the circumstances of care surrounding death and demographic information. In total, a bank of 123 questions were prioritised to be included in the National End of Life Survey instrument.

CONCLUSION

The survey will provide a standardised national approach to capturing the experience of care of those who have died, from the perspective of bereaved relatives in the Republic of Ireland. This will allow health service providers, policy makers and regulators to gather important insights into the experiences of care at end of life and will help fulfil the requirement of healthcare services to ensure they are providing high-quality care.

Assisted decision-making and interprofessional collaboration in the care of older people: a qualitative study exploring perceptions of barriers and facilitators in the acute hospital setting

In recent years, there has been a move toward a more human rights-based approach to the issue of supported and assisted decision-making (ADM) with legislative changes strengthening the formal right for older people to participate in care planning and decision-making. Ireland's Assisted Decision-Making (Capacity) Act, 2015 breaks from traditional views of capacity to consider the uniqueness of each decision in relation to topic, time and place for those with impaired or fluctuating capacity. This study set out to explore experiences of assisted decision making (ADM) in acute care hospitals in Ireland and to identify the barriers and enablers to ADM for older people and people with dementia from the perspective of different Health and Social Care Professionals (HSCPs) involved in their care. We carried out 26 semi-structured audio-recorded interviews with a convenience sample of HSCPs working in two acute hospitals and subsequently confirmed the results. HSCPs identified several barriers to, and enablers of, ADM in acute hospitals that were categorized into three key themes: Building meaningful engagement with older people and their family carers; barriers and enablers associated with interprofessional collaboration and barriers and enablers associated with the environment. Our findings suggest that despite concrete policy and legislative underpinnings to ADM, this was not always evident in practice and suggests the need for specialized education and training on ADM in practice settings.

Dying in acute hospitals: voices of bereaved relatives

Background

Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals.

Methods

Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate).

Results

The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support.

Conclusions

This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative’s priorities for EoLC in acute hospitals and can advance care providers’, policy makers’ and educationalists’ priorities for service improvement.

171 Programme Theory to Guide the Adoption of Assisted Decision Making with Older People in Acute Healthcare: Realist Evaluation

Background

In Ireland, the Assisted Decision-Making (ADM) (Capacity) Act and emerging Codes of Practice provide a legal framework for Healthcare Professionals (HCPs) to enable ADM for patients with impaired capacity. ADM ensures that a person’s will and preference is at the centre of all decisions related to their care. This study conducted a realist evaluation and developed a Programme Theory (PT) to highlight how ADM for older people can be operationalised within an Acute Care (AC) context.

Methods

Key informants with interest in ADM informed this evaluation. Interviews were conducted in two Acute Care (AC) sites with multidisciplinary HCPs working within older person services (n=20). Interviews with informants that recently received care within an AC setting involved older people (n=3) people with dementia (n=4) and family carers (n=5). Ethnographic observations from AC multidisciplinary team meetings also informed the review. The framework that guided the qualitative analysis was from a PT informed by literature on ADM implementation in healthcare (O'Donnell, Ní Shé, Davies et al.2018).

Results

The refined PT is supported by credible evidence that is informed by authentic experiences of decision making support in the AC setting. Validation groups (n=4) with the key informants verified the PT. Three mechanisms were identified as a positive climate and receptive environment for the adoption of formal ADM. These are:

AC settings that adopt inter-professional accountability and shared responsibility for patient care that is guided by a clear policy process. Acute care and practice that is informed by a shared commitment to person-centred care and shared decision making. HCPs that operate within an AC setting where organisational learning informs practice through inter-professional training, mentorship and peer support.

Conclusion

Involving stakeholders in PT development enhances the utility, feasibility and applicability of the results. This PT provides a framework for those planning ADM implementation within the AC settings.

153 Barriers and Enablers of Assisted Decision-making for Older People in Acute Care Hospitals: A Multi-Stakeholder Inquiry

Background

Ireland’s Assisted Decision-Making (Capacity) Act 2015 breaks from traditional views of capacity to consider the uniqueness of each decision with relation to topic, time and place for those with impaired or fluctuating capacity. It has yet to be commenced, however codes of practice and educational strategies are in development to support health and social care professionals (HSCPs) to practice in accordance with the Act. This study set out to examine barriers and enablers to the adoption of assisted decision making (ADM) involving older people in acute hospitals from multiple perspectives. It describes a pre-implementation formative evaluation informed by the perspectives of relevant stakeholders in ADM practice.

Methods

In total, 12 key informant interviews and two validation groups were conducted with family carers and older people with and without a diagnosis of dementia in two acute hospitals. In addition, 20 interviews and two validation groups were conducted with HSCPs. Interviews focused on contextual characteristics as well as barriers and enablers of ADM.

Results

Barriers and enablers included supporting capacity through adopting a functional approach, the physical environment where decision-making takes place, meeting information and support needs, methods of communication, upholding will and preferences, relationships and trust. Time and timing were consistently identified as a critical factor. HSCPs also highlighted the need for specialised education and training on ADM practice.

Conclusion

The issues identified around ADM will inform the development of a serious discussion game on acute care scenarios, which will be deployed for awareness raising and educational purposes. Findings will also help focus attention on how those working within complex health systems and organisations can practically implement changes to practice in line with ADM legislation.

214 Advance Care Planning: Perspectives of People with Dementia and their Family Members

Background

Clear and effective communication is central to all aspects of healthcare. Discussions centred on advance care planning are vital to ensure the person with dementia receives the support and care they need in the future based on their will and preferences. The aim of this study was to ascertain from those provided with information on advance care planning if it met their needs and assisted their understanding on planning for the future.

Methods

This study centred on eliciting the views of older persons diagnosed with dementia and their carers on the provision of an information booklet titled ‘I have dementia ... How do I plan for the future’. Ethical approval was sought and provided to conduct this study.  Participants presenting to an acute hospital day ward for older persons were identified and recruited through the medicine for older person’s team. 42 people consented to participate with 20 people returning questionnaires, a 48% response rate. Thematic analysis was applied to qualitative comments and descriptive statistical analysis was undertaken with quantitative data.

Results

The overwhelming majority (95%) of respondents found the provision of an information booklet on advance care planning helpful. Nearly two thirds (65%) spoke with someone about advance care planning thereafter. 60% of all respondents reporting that the booklet was either ‘easy’ or ‘very easy’ (40%) to understand. Participants strongly endorsed the provision of information on advance care planning and the benefits that it bestowed to them.

Conclusion

The study has confirmed the importance of communication and the provision of information on advance care planning for people with dementia and their carers in the day ward setting for older persons. Findings strongly endorse the information provided whilst also suggesting minor amendments to the booklet to improve future editions.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives

Background

End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland.

Methods

This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient’s last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach.

Results

Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication.

Conclusions

Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.