Dying a 'Good' Death: The Work, Care, and Support of End-of-Life Doulas

End-of-life doulas (EOLDs) are a growing population of care providers who focus on the wishes of the dying person in order to cultivate an environment of comfort, peace, and support from the point of terminal diagnosis, during the dying process, and following death. The purpose of this study was to document the time commitment of EOLDs to dying persons and their loved ones during the dying process, as well as their experiences navigating family dynamics working towards increased acceptance of death. A mixed-methods approach was utilized to gather data on EOLDs, consisting of a quantitative survey with 618 respondents and subsequent qualitative interviews conducted with 39 participants. Results indicated that the amount of time spent with dying persons and their loved ones varies widely and often depends on when the EOLD is contracted regarding services. Factors that impede and lead to great acceptance of death are discussed as well as the role of EOLDs in navigating family dynamics.

The Relationship between Practitioners and Caregivers during a Treatment of Palliative Care: A Grounded Theory of a Challenging Collaborative Process

The possibility of coming to a “good death” is a challenging issue that crosses ethical and religious beliefs, cultural assumptions, as well as medical expertise. The provision of palliative care for relieving patients’ pain is a practice that reshapes the path to the event of death and gives form to a particular context of awareness, recalling the notion proposed by Glaser and Strauss. This decision redesigns the relationships between patients, practitioners and caregivers and introduces a new pattern of collaboration between them. Our study focuses on the implications of the collaboration between practitioners and caregivers, starting from the assumption that the latter may provide support to their loved ones and to the practitioners, but need to be supported too. We provide a qualitative analysis of this collaboration based on an empirical research that took place in four different settings of provision of palliative care, reporting the contrast between the affective engagement of caregivers and the professional approach of practitioners. We claim that this ambivalent collaboration, while embedded in contingent and incommensurable experiences, brings to the fore the broader understanding of the path to a “good death,” outlining its societal representation as a collective challenge.

Taking care of dying patients through an 'interprofessional ecosystem': a grounded theory study on the experience of an interprofessional team in palliative care

BACKGROUND

The interprofessional approach is part of the philosophy in palliative care, and its benefits are already documented. However, there are no evidence regarding the process through which the interprofessional team faces the process of the patient's end-of-life and how this experience might be of value for the team's development itself. The aim of this study was to analyse and understand the psychosocial processes that occurs when an interprofessional team accompanies patients and their families to death in palliative care, with the ultimate aim to develop a substantive theory to describe this phenomenon.

METHODS

A Grounded Theory method, as theorized by Strauss and Corbin, was adopted for this study. Data were collected through semi-structured interviews and then independently analysed using constant comparison analysis. Fourteen healthcare professionals - belonging to different disciplines (doctor, nurse coordinator, nurse, nurse assistant, psychologist) - were interviewed in a Northern Italy palliative care facility.

FINDINGS

The core category of this study was identified to be the process of accompaniment of the dying patient as an interprofessional ecosystem. Moreover, the results showed four main factors determining the development of the core psychosocial process: from professionals' 'Hidden Amazement' to 'Onerous Happiness' where 'Weaving of Professional Resources' and 'Work Meaning' are the underlying conditions to catalyse the process itself.

CONCLUSION

Interprofessional care appears an essential value, which becomes the source of the team's strength when facing end-of-life experiences. Health policies and organisations should take the importance of the characteristics of the work environment more carefully. The meaning that professionals attribute to their work and to the team itself, indeed, it may have impact on the overall quality of care and contribute to sustain work engagement, even in stressful situations like end-of-life care.

Farewell Letters I: The Dying Process of a Healthy Man

This qualitative case study describes the dying process from a purely psychological perspective. The letters of Count Moltke, who was sentenced to death and executed during the Nazi regime, to his wife were analyzed content analytically. A work program of four self-imposed tasks emerged, namely first to avert the death sentence, second to prepare for the ideological and intellectual battle with the chairman of the court, third to support his wife in her anticipatory mourning, and fourth to achieve willingness for his dying by strangulation and for losing his life. Contrasting these findings with two cases of incurably ill men confirmed work and structure as the overarching way of coping. Religious coping is also of central importance. There was neither a linear trajectory nor a sequence of phases; rather, Moltke's dying process corresponds to a circular model. A consequence of the findings is outlined.

Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later

CONTEXT

Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome.

OBJECTIVES

The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs.

METHODS

Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death.

RESULTS

Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57).

CONCLUSION

The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.

Tairyoku as a belief system of health and illness: a study of cancer patients in Japan

The aim of this paper is to investigate the concept of tairyoku (body power) within the context of palliative care in contemporary Japan, and to explore its use by cancer patients at palliative care units (PCUs). Tairyoku is thought to be vital energy, analogous to qi in Chinese Medicine. In this paper it is shown that tairyoku is used to monitor bodily condition by patients and that it plays an important role in treatment decision-making for them. Medical professionals also use the word tairyoku; however, they do not agree with the patients' idea of increasing tairyoku in order to cure cancer. This situation causes disagreement about treatment between patients and medical staff at PCUs; however, this paper will show that tairyoku is the important concept to help patients manage their illness and sustain their autonomy, and finally accept imminent death.