Interdisciplinary research approach based on a mixed-methods design to explore patient altruism at the end of life: a study protocol

INTRODUCTION

In the end of life context, patients are often seen as somewhat passive recipients of care provided by health professionals and relatives, with little opportunity to be perceived as autonomous and active agents. Since studies show a very high prevalence of altruistic dispositions in palliative care patients, we strive to investigate the concept of patient altruism in a set of six interdisciplinary studies by considering three settings: (1) in the general palliative context-by studying to what extent patient altruism is associated with essential psychological outcomes of palliative care (subproject 1a), how altruism is understood by patients (subproject 1b) and how altruism expressed by patients is experienced by palliative care nurses (subproject 1c); (2) in two concrete decision-making contexts-advance care planning (subproject 2a) and assisted suicide (subproject 2b); and (3) through verbal and non-verbal patient communication in palliative care settings (subproject 3).

METHODS AND ANALYSIS

Subproject 1a: a cross-sectional study using validated and standardised questionnaires. Subprojects 1b and 1c: a constructivist grounded theory method aiming at developing a novel theory from semistructured interviews in both patients and nurses. Subproject 2a: a thematic analysis based on (1) audio-recordings of advance care planning encounters and (2) follow-up semidirective interviews with patients and their relatives. Subproject 2b: a qualitative study based on thematic analysis of interviews with patients actively pursuing assisted suicide and one of their relatives.Subproject 3: a conversation analysis based on audio and video-recorded interactions in two settings: (1) palliative inpatient unit and (2) advance care planning discussions.

ETHICS AND DISSEMINATION

The study project was approved by the Ethics Committees of the Canton of Vaud, Bern and Ticino (no: 2023-00088). In addition to participation in national and international conferences, each project will be the subject of two scientific publications in peer-reviewed journals. Additional publications will be realised according to result triangulation between projects. A symposium opened to professionals, patients and the public will be organised in Switzerland at the end of the project.

Patient altruism at the end of life: A scoping review

OBJECTIVES

The concept of altruism is evidenced in various disciplines but remains understudied in end-of-life (EOL) contexts. Patients at the EOL are often seen as passive recipients of care, whereas the altruism of professionals and families receives more research and clinical attention. Our aim was to summarize the state of the scientific literature concerning the concept of patient altruism in EOL contexts.

METHODS

In May 2023, we searched 11 databases for scientific literature on patient altruism in EOL contexts in consultation with a health information specialist. The scoping review is reported using the PRISMA checklist for scoping reviews. We used a data charting form to deductively extract data from the selected articles and then mapped data into 4 themes related to our research questions: how authors describe and employ the concept of patient altruism; expressions of patient altruism; consequences of patients' altruistic acts; and possible interventions fostering patient altruism.

RESULTS

Excluding duplicates, 2893 articles were retrieved; 33 were included in the final review. Altruism was generally considered as an act or intention oriented toward the benefit of a specific (known) or non-specific (generic) recipient. Patients expressed altruism through care and support, decisions to withhold treatment or actively hasten death, and engagement in advance care planning. Consequences of altruism were categorized in patient-centered (contribution to meaning in life and quality of life), non-patient-centered (leaving a positive impact and saving money), and negative consequences (generating feelings of guilt, exposing individuals with low self-esteem). Interventions to encourage altruism comprised specific interventions, providing opportunities to plan for future care, and recognizing and respecting the patients' altruistic motivations.

SIGNIFICANCE OF RESULTS

We identified heterogeneous and limited research conceptualization of patient altruism and its operationalization in palliative care settings. A deeper conceptual, empirical, and theoretical exploration of patient altruism in EOL is necessary.

Advance Care Planning: A Story of Trust Within the Family

As the family usually plays a central role at the end of life, the quality of family relationships may influence how individuals approach advance care planning (ACP). Our study investigates the associations of trust in relatives with regard to end-of-life (EOL) issues-used as a proxy measure of family relationship quality-with individuals' engagement in EOL discussions, advance directive (AD) awareness, approval and completion, and designation of a healthcare proxy. Using nationally representative data of adults aged 55 years and over from wave 6 (2015) of the Survey of Health, Ageing, and Retirement in Europe (SHARE) in Switzerland (n = 1911), we show that complete trust in relatives is related to higher engagement in ACP. Subject to patient consent, the family should, therefore, be included in the ACP process, as such practice could enhance patient-centered EOL care and quality of life at the end of life.

Cognitive abilities and engagement in advance care planning among older adults: Results of a Swiss populational study

Individuals often wait until the last moment to plan their end-of-life (EOL) care. Yet, decision-making capacity decreases with age, which could compromise engagement in and the effectiveness of advance care planning (ACP). Little is known about the association between cognitive abilities and the steps involved in the multifaceted process of ACP in older adults. The present study aims to better understand the association of global cognitive competence with engagement in ACP in a nationally representative sample of older adults in Switzerland. Global cognitive competence was measured via verbal fluency, immediate and delayed memory, basic calculation skills, and temporal orientation. Engagement in ACP included approving advance directives, having discussed EOL preferences, having a living will, and having a health care proxy. We analyzed data of 1,936 respondents aged 55+ from a paper-and-pencil questionnaire that was administered as part of Wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe in Switzerland using logistic regression models. Respondents with reduced global cognitive competence are less likely to have discussed their EOL preferences with others and to have a living will. Our results also indicate an interaction between age and cognition with respect to having a living will. Individuals with lower global cognitive competence in the oldest age group-adults aged 75 and older-are less likely to have a living will. Our findings highlight that low global cognitive competence can be seen as a barrier to engagement in ACP, particularly among adults 75 years and older. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Overestimation of Survival Rates of Cardiopulmonary Resuscitation Is Associated with Higher Preferences to Be Resuscitated: Evidence from a National Survey of Older Adults in Switzerland

BACKGROUND

Many widely used advance directives templates include direct questions on individuals' preferences for cardiopulmonary resuscitation (CPR) in case of decision-making incapacity during medical emergencies. However, as knowledge of the survival rates of CPR is often limited, individuals' advance decisions on CPR may be poorly aligned with their preferences if false beliefs about the survival rates of CPR shape stated preferences for CPR.

METHODS

We analyzed nationally representative data from 1,469 adults aged 58+ y who responded to wave 8 (2019/2020) of the Swiss version of the Survey on Health, Ageing, and Retirement in Europe (SHARE) to assess the partial association between knowledge of CPR survival rates and stated preferences for CPR using multivariable probit regression models that adjust for social, health, and regional characteristics. Knowledge of CPR survival rates was assessed by asking how likely it is in general in Switzerland for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital. Preferences for CPR were measured by asking respondents if they would wish to be resuscitated in case of cardiac arrest.

RESULTS

Only 9.3% of respondents correctly assessed the chances for a 70-y-old to survive until hospital discharge from a CPR performed outside of a hospital, while 65.2% indicated a preference to be resuscitated in case of a cardiac arrest. Respondents who correctly assessed CPR survival were significantly more likely to wish not to be resuscitated (average marginal effect: 0.18, P < 0.001).

CONCLUSIONS

Reducing misconceptions concerning the survival rates of CPR could change older adults' preferences for CPR and make them more likely to forgo such treatments.

HIGHLIGHTS

Many older adults in Switzerland overestimate the survival rates of cardiopulmonary resuscitation (CPR).The study reveals that individuals with accurate knowledge of CPR survival rates are more likely to refuse resuscitation in case of cardiac arrest.Overestimation of CPR survival rates may lead to a mismatch between individuals' preferences for CPR and their actual end-of-life care decisions.Improving the general population's knowledge of CPR survival rates is crucial to ensure informed decision making and effective advance care planning.

'Thank you for loving me': A qualitative study on perceptions of gratitude and their effects in palliative care patients and relatives

BACKGROUND

Empirical studies suggest that gratitude positively influence the quality of life of palliative patients and relatives. However, the literature is marked by a lack of conceptual clarity about what gratitude is and whether it can bring about individual and social benefits.

AIM

This paper explores how palliative care patients and relatives understand gratitude, how discursive representations of gratitude may affect their positions, perceptions and relations, and how to conceptualise gratitude in the palliative context.

DESIGN

We examine 33 gratitude letters written by patients and relatives and 25 semi-structured interviews conducted as part of a pilot gratitude intervention study. We use a qualitative approach, thematic analysis, within a conceptual framework of discourse analysis.

SETTINGS/PARTICIPANTS

Data were collected from 23 patients and 13 relatives recruited through three hospital palliative care services in French-speaking Switzerland.

RESULTS

Participants articulate gratitude in five ways: (1) appreciating others; (2) love; (3) need to reciprocate; (4) appreciating the little things; (5) solace amid serious illness. While some of these representations are sources of positive emotions and outlook, wellbeing and hope, others may confirm self-perceptions of powerlessness and burden. These results support a tridimensional conceptualisation of gratitude in palliative care as source of individual benefits, valuing closest relationships and moral obligation.

CONCLUSION

Our study suggests that gratitude is a key to a good (end of) life, whilst highlighting potential negative effects. It could help healthcare professionals to better understand what gratitude means to patients and relatives, which may facilitate awareness and fostering of gratitude in palliative care.

Older adults' medical preferences for the end of life: a cross-sectional population-based survey in Switzerland

OBJECTIVES

Medical decision-making at the end of life is common and should be as patient-centred as possible. Our study investigates older adults' preferences towards three medical treatments that are frequently included in advance directive forms and their association with social, regional and health characteristics.

SETTING

A cross-sectional study using population-based data of wave 8 (2019/2020) of the Swiss component of the Survey of Health, Ageing and Retirement in Europe.

PARTICIPANTS

1430 adults aged 58 years and older living in Switzerland.

PRIMARY AND SECONDARY OUTCOME MEASURES

Three questions on the preferences regarding cardiopulmonary resuscitation (CPR); life-prolonging treatment in case of high risk of permanent mental incapacity; reduced awareness (sedation) to relieve unbearable pain and symptoms. Their associations with individuals' social, regional and health characteristics.

RESULTS

Most older adults expressed a wish to receive CPR (58.6%) and to forgo life-prolonging treatment in case of permanent mental incapacity (92.2%). Most older adults also indicated that they would accept reduced awareness if necessary to receive effective treatment for pain and distressing symptoms (59.2%). Older adults' treatment preferences for CPR and life-prolonging treatment differed according to sex, age, partnership status, linguistic region and health status, while willingness to accept reduced awareness for effective symptom treatment was more similarly distributed across population groups.

CONCLUSIONS

Simultaneous preferences for CPR and refusal of life-prolonging treatment might appear to be conflicting treatment goals. Considering individuals' values and motivations can help clarify ambivalent treatment decisions. Structured advance care planning processes with trained professionals allows for exploring individuals' motivations and values and helps to identify congruent care and treatment goals.

Giving and receiving thanks: a mixed methods pilot study of a gratitude intervention for palliative patients and their carers

BACKGROUND

Psychological research examining the nature and workings of gratitude has burgeoned over the past two decades. However, few studies have considered gratitude in the palliative care context. Based on an exploratory study which found that gratitude was correlated with better quality of life and less psychological distress in palliative patients, we designed and piloted a gratitude intervention where palliative patients and a carer of their choice wrote and shared a gratitude letter with each other. The aims of this study are to establish the feasibility and acceptability of our gratitude intervention and provide a preliminary assessment of its effects.

METHODS

This pilot intervention study adopted a mixed-methods, concurrent nested, pre-post evaluation design. To assess the intervention's effects, we employed quantitative questionnaires on quality of life, quality of relationship, psychological distress, and subjective burden, as well as semi-structured interviews. To assess feasibility, we considered patients and carers' eligibility, participation and attrition rates, reasons for refusal to participate, appropriateness of intervention timeframe, modalities of participation, and barriers and facilitators. Acceptability was assessed through post-intervention satisfaction questionnaires.

RESULTS

Thirty-nine participants completed the intervention and twenty-nine participated in interviews. We did not find any statistically significant pre/post intervention changes for patients, but found significant decrease in psychological distress for carers in terms of depression (median = 3 at T0, 1.5 at T1, p = .034) and total score (median = 13 at T0, 7.5 at T1, p = .041). Thematic analysis of interviews indicates that overall, the intervention had: (1) multiple positive outcomes for over a third of interviewees, in the form of positive emotional, cognitive, and relational effects; (2) single positive outcomes for nearly half of interviewees, who experienced emotional or cognitive effects; (3) no effect on two patients; and (4) negative emotional effects on two patients. Feasibility and acceptability indicators suggest that the intervention was well received by participants, and that it should adopt flexible modalities (e.g. writing or dictating a gratitude message) to ensure that it is feasible and adapted to individual needs and preferences.

CONCLUSIONS

Larger scale deployment and evaluation of the gratitude intervention, including a control group, is warranted in order to have a more reliable evaluation of its effectiveness in palliative care.

Methods for informing people with amyotrophic lateral sclerosis/motor neuron disease of their diagnosis

BACKGROUND

Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND), causes increasing physical impairment and disability. People with ALS/MND face huge physical challenges, and the diagnosis can be a source of great psychological distress for both people with ALS/MND and their carers. In such a context, how news of the diagnosis is broken is important. At present, there are no systematic reviews of methods for informing people with ALS/MND of their diagnosis.

OBJECTIVES

To examine the effects and effectiveness of different methods for informing people of a diagnosis of amyotrophic lateral sclerosis/motor neuron disease (ALS/MND), including effects on the person's knowledge and understanding of their disease, its treatment, and care; and on coping and adjustment to the effects of ALS/MND, its treatment, and care.

SEARCH METHODS

We searched the Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers (February 2022). We contacted individuals or organisations to locate studies. We contacted study authors to obtain additional unpublished data.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) and quasi-RCTs of techniques for informing people with ALS/MND of their diagnosis. We planned to include adults (aged 17 years or over) with ALS/MND, according to the El Escorial criteria.

DATA COLLECTION AND ANALYSIS

Three review authors independently reviewed the results of the search to identify RCTs, and three review authors identified non-randomised studies to include in the discussion section. We planned that two review authors would independently extract data, and three would assess the risk of bias in any included trials.

MAIN RESULTS

We did not identify any RCTs that met our inclusion criteria.

AUTHORS' CONCLUSIONS

There are no RCTs that evaluate different communication strategies for breaking the bad news for people diagnosed with ALS/MND. Focused research studies are needed to assess the effectiveness and efficacy of different communication methods.

"More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit

Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit.

CONCLUSION

This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families.

WHAT IS KNOWN

• Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described.

WHAT IS NEW

• Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.

"Life goes on": Perspectives on the will to live from residents of Swiss long-term care facilities

OBJECTIVES

While there is a growing body of literature on the wish to die in older patients, there is little research about their will to live. Exploring the subjective will to live (WTL) offers valuable insights into the patients' resources and motivations, which could help improving geriatric palliative care. The aim of this study was to examine, in long-term care facilities (LTCF), residents' definitions of and factors influencing their WTL.

METHODS

Twenty residents (mean age 85.8 ± 10.3 years, 70% women) of 3 Swiss LTCFs gave informed consent and participated in semi-structured interviews about their WTL. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify recurrent themes (40% double coded).

RESULTS

The majority of residents reported that they had not thought about the WTL. Nevertheless, they had no difficulty in describing it as innate in their lives. They spontaneously mentioned factors that contributed to their WTL, classified into 5 themes: (1) relationships - primarily with family and health professionals, secondarily with other residents; (2) living situation - the LTCF as a necessary place providing care, constant professional presence, and security, yet necessitates inconveniences such as loss of independence; (3) personality factors - positive outlook on life or spirituality; (4) engagement in routines - organized activities and individual daily routines; and (5) health status - primarily related to functional health.

SIGNIFICANCE OF RESULTS

Examining WTL provides important insights into elements that are essential to take into account in planning care and promoting well-being in LTCF residents. The themes identified provide important starting points for improving life in LTCFs.

Perceptions and Knowledge Regarding Medical Situations at the End of Life among Older Adults in Switzerland

Background: Perceptions and knowledge regarding end-of-life health and health care can influence individuals' advance care planning, such as the completion and content of advance directives. Objectives: To assess older adults' perceptions of medical end-of-life situations in Switzerland along with their accuracy and corresponding associations with sociodemographic characteristics. Design: This is an observational study. Setting/study subjects: A nationally representative sample of adults aged 58 years and older who participated in wave 8 (2019/2020) of the Swiss part of the Survey of Health, Ageing, and Retirement in Europe (cooperation rate: 94.3%). Measurements: Subjective likelihood of 11 end-of-life situations on a 4-point scale: very unlikely (0-25%), rather unlikely (26%-50%), rather likely (51%-75%), and very likely (76%-100%). Results: Older adults' perceptions of end-of-life medical situations in Switzerland were rather heterogeneous and often inaccurate. Study subjects overestimated the success of cardiopulmonary resuscitation, the utility of a fourth-line chemotherapy, of hospital admission for pneumonia for patients with advanced dementia, and for artificial nutrition and hydration in the dying phase, while underestimating the effectiveness of pain management in this situation. Less than 28% of older adults correctly assessed the likelihood of dying in a nursing home, hospital, or at home, respectively. Inaccurate views were more frequent in men (p < 0.01) and individuals with financial difficulties (p < 0.05), whereas adults aged 75+ years (p < 0.01) and respondents from the German-speaking part of Switzerland (p < 0.01) had more accurate perceptions. Conclusions: The wide variation and low accuracy of end-of-life perceptions suggest considerable scope for communication interventions about the reality of end-of-life health and health care in Switzerland.

HEALTH LITERACY AMONG OLDER ADULTS IN SWITZERLAND: CROSS-SECTIONAL EVIDENCE

Despite being widely regarded as a major cause of health inequalities, little is known regarding levels of health literacy among older adults in Switzerland. To fill this gap, this study assesses health literacy and its associations with individuals’ social, regional, and health characteristics in a nationally representative sample of adults aged 58 years and older in Switzerland. We use data of 1’625 respondents from a paper-and-pencil self-completion questionnaire that was administered as part of wave 8 (2019/2020) of SHARE in Switzerland. Health literacy is measured using the short version of the European Health Literacy Survey questionnaire (HLS-EU-Q16). We use multivariable regressions to explore how respondents' sociodemographic characteristics are independently associated with health literacy. Overall, 6,8% of the respondents had inadequate health literacy, 24,6% problematic health literacy, and 68,6% sufficient health literacy. There were significant associations between health literacy and individuals' gender, education, economic situation, and self-rated health. Women had higher levels of health literacy than men (p < 0,001). Moreover, a higher education level (p < 0,001), fewer financial difficulties (p< 0.01), and higher self-rated health (p < 0,001) were positively correlated with adequate/higher levels of health literacy. One-third of older citizens have difficulties managing health-related issues in Switzerland. These findings call for targeted interventions, such as using simplified health or eHealth information tools, improved patient-provider communication, and shared decision-making, promoting lifelong learnings activities and health literacy screening for older patients to increase low health literacy and mitigate its consequences, thereby alleviating remaining social health inequalities in the Swiss population.

PERSONALITY TRAITS AND END-OF-LIFE ATTITUDES AND BEHAVIORS IN OLDER ADULTS: EVIDENCE FROM SHARE

Personality traits (PTs) - Neuroticism, Extraversion, Openness to experience, Agreeableness, Conscientiousness - are related to decision-making styles, as well as to specific end-of-life (EOL) healthcare preferences. Building on this knowledge, our study aims to explore the association of PTs with attitudes and behaviours towards the EOL in general and EOL care planning in particular. Our analyses are based on a paper-and-pencil self-completion questionnaire (n=1’524) administered as part of wave 6 and 7 of SHARE in Switzerland. PTs are measured with the Big-Five inventory ten (BFI-10). Attitudes and behaviours related to EOL are: outlook −avoid thinking about death, think about and discuss EOL preferences−, administrative arrangements −testament, power of attorney−, approval and completion of advance care planning. Results show that older adults with higher scores on openness are more likely to think, plan and discuss EOL, as well as to have made arrangement in advance such as a testament, and a power of attorney. Higher scores on extraversion are linked with having a testament. Individuals who express higher scores on neuroticism more often think about their wishes for EOL, whereas those scoring higher on agreeableness are less likely to be in favour of advance care planning. To conclude, older adults in Switzerland remain unfamiliar with EOL topics, since only individuals with higher openness to experience are more prone to prepare for the EOL. PTs should be taken into account when educating and encouraging people to plan for their EOL.

END-OF-LIFE HEALTH LITERACY: VALIDATION STUDY OF A NEW INSTRUMENT, THE END-OF-LIFE HEALTH LITERACY SCALE (EOL-HLS)

Measuring health literacy allows to assess individuals’ competencies to deal with health issues; it influences how individuals perceive their health problems, communicate with healthcare providers, or make medical decisions. The end of life is commonly characterized by one or several diseases, healthcare services’ uses and requires individuals to make complex medical decisions. Although the end-of-life concerns everyone, the level of competencies of individuals to get through this stage of life has been little explored. This study aims to fill this gap by validating a new instrument, the End-of-life Health Literacy Scale (EOL-HLS), in a representative sample of older adults aged 58+ living in Switzerland. We use the Swiss wave 8 (2019/2020) of SHARE. Based on the seminal work of Nutbeam (2000), end-of-life health literacy skills are measured using questions on the difficulty in understanding medical interventions, finding information, communicating, deciding in advance, and choosing end-of-life care options. In addition, we compare the findings to the European Health Literacy Survey questionnaire (HLS-EU-Q16). The results confirmed the suitability for performing factor analysis (KMO = 0.924, Bartlett’s test of sphericity statistically significant), a three-factor model was established and showed good fit properties (CFI = 0.964, TLI = 0.958, RMSEA = 0.047, SRMR = 0.067) and good reliability (α = 0.93). The associations found between individuals’ sociodemographic characteristics and the HLS-EU-Q16 were also present in our instrument, but higher EOL-HLS scores were associated with more positive end-of-life outcomes. The EOL-HLS is a reliable and valid instrument to target individuals with low end-of-life health literacy.

Posttraumatic growth in palliative care patients and its associations with psychological distress and quality of life

OBJECTIVES

Posttraumatic growth (PTG) refers to positive psychological changes resulting from individuals' inner struggles with traumatic events such as life-threatening illness. Although palliative care patients are confronted with their own mortality, little is known about their PTG experience. This study investigates whether PTG is an empirically relevant concept for palliative patients by assessing the prevalence and areas of growth, and examining associations with psychological distress and quality of life.

METHODS

Participants were recruited in Switzerland. Using validated questionnaires, we assessed PTG (Posttraumatic Growth Inventory, PTGI), psychological distress (Hospital Anxiety and Depression Scale), and quality of life (McGill-Quality of Life Questionnaire - Revised). We performed descriptive analyses, Spearman correlations, and linear regressions.

RESULTS

Fifty-five patients completed the PTGI, 44% of whom experienced no/low growth, 47% moderate growth, and 9% high/very high growth. Participants experienced the greatest positive changes in terms of appreciating life and relating to others. We found significant negative bivariate correlations between PTG and psychological distress (r = -0.33) and between PTG and depression (r = -0.47). Linear regressions showed that PTG is associated with depression (β = -0.468; p = 0.000), but not with anxiety or quality of life (adjusted R² = 0.219).

SIGNIFICANCE OF RESULTS

Over half of our patients experienced moderate to very high growth, indicating that PTG is an empirically relevant psychological process in palliative care. PTG is associated with lower levels of depression, possibly as those experiencing growth are more able to process past traumas and build a more positive outlook on one's life and self. By contrast, the relative independence of anxiety and PTG points to the likely coexistence of positive and negative psychological responses to trauma. The lack of association between PTG and quality of life points to the uniqueness of the PTG concept in capturing how people access deeper meaning and greater appreciation of life along the path toward posttraumatic self-reconstruction.

‘We Have Guidelines, but We Can Also Be Artists’: Neurologists Discuss Prognostic Uncertainty, Cognitive Biases, and Scoring Tools

Introduction: Ischemic stroke is a leading cause of disability and mortality worldwide. As acute stroke patients often lose decision-making capacity, acute management is fraught with complicated decisions regarding life-sustaining treatment (LST). We aimed to explore (1) the perspectives and experiences of clinicians regarding the use of predictive scores for LST decision making in severe acute stroke, and (2) clinicians’ awareness of their own cognitive biases in this context. Methods: Four focus groups (FGs) were conducted with 21 physicians (13 residents and 8 attending physicians); two FGs in a university hospital and two in a regional hospital in French-speaking Switzerland. Discussions were audio-recorded and transcribed verbatim. Transcripts were analyzed thematically. Two of the four transcripts were double coded to establish coding framework consistency. Results: Participants reported that predictive tools were not routinely used after severe stroke, although most knew about such scores. Scores were reported as being useful in quantifying prognosis, advancing scientific evidence, and minimizing potential biases in decisions. Their use is, however, limited by the following barriers: perception of inaccuracy, general disbelief in scoring, fear of self-fulfilling prophecy, and preference for clinical judgement. Emotional and cognitive biases were common. Emotional biases distort clinicians’ knowledge and are notably: bias of personal values, negative experience, and cultural bias. Cognitive biases, such as availability, confirmation, and anchoring biases, that produce systematic deviations from rational thinking, were also identified. Conclusions: The results highlight opportunities to improve decision making in severe stroke through the promotion of predictive tools, strategies for communicating prognostic uncertainty, and minimizing cognitive biases among clinicians, in order to promote goal-concordant care.

Goals of care changes after acute ischaemic stroke: decision frequency and predictors

OBJECTIVES

Little is known about the factors leading to a change in goals of care (CGC) in patients with an acute ischaemic stroke (AIS). Our aim was to analyse the proportion and outcome of such patients and identify medical predictors of a CGC during acute hospitalisation.

METHODS

We retrospectively reviewed all patients who had an AIS over a 13-year period from the prospectively constructed Acute Stroke Registry and Analysis of Lausanne. We compared patients with a CGC during the acute hospital phase to all other patients and identified associated clinical and radiological variables using logistic regression analysis.

RESULTS

A CGC decision was taken in 440/4264 (10.3%) consecutive patients who had an AIS. The most powerful acute phase predictors of a CGC were transit through the intensive care unit, older age, pre-existing disability, higher stroke severity and initial decreased level of consciousness. Adding subacute phase variables, we also identified active oncological disease, fever and poor recanalisation as predictors. 76.6% of the CGC patients died in the stroke unit and 1.0% of other patients, and 30.5% of patients with a CGC received a palliative care consultation. At 12 months, 93.6% of patients with CGC had died, compared with 10.1% of non-CGC patients.

CONCLUSIONS

Over three-quarters of AIS patients with CGC died in hospital, but less than a third received a palliative care consultation. The identified clinical and radiological predictors of a CGC may allow physicians to initiate timely the decision-making process for a possible CGC.

The involvement of palliative care with neurology – a comparison of UK, Switzerland and Italy

OBJECTIVES

To ascertain the involvement of palliative care with neurology services in the care of people with amyotrophic lateral sclerosis (ALS) in the United Kingdom, Italy and Switzerland, in particular the collaboration with and referral from neurology, the involvement in multidisciplinary team care and in the respiratory support of ALS patients.

METHODS

In 2019, two online surveys were undertaken of palliative care specialists, using specialist groups of the European Academy of Neurology, European Association of Palliative Care and the Association of Palliative Medicine for Great Britain and Ireland.

RESULTS

The respondents were specialist palliative care professionals, predominantly senior doctors, involved in the care of people with ALS. As the numbers of respondents from many countries were in single figures the analysis was restricted to the United Kingdom, Italy and Switzerland. The time of involvement varied, with early involvement commonest in the UK. Barriers to referral included neurologists not referring and financial issues, particularly in Switzerland. The reluctance of patients and families to see palliative care services was reported as less than 20% in all countries. Respondents were often involved in the care of people receiving noninvasive ventilation (NIV), in all countries. and with tracheostomy ventilation (TV), particularly in Italy.

CONCLUSIONS

Palliative care services are often involved in the care of people with ALS, but the extent and timing of involvement varies. The use of clinical guidelines and education on palliative care for neurology services may encourage collaboration, for the benefit of people with ALS and their families.

Knowledge Gaps in End-of-Life Care and Planning Options Among Older Adults in Switzerland

Objectives: Good knowledge about end-of-life (EOL) care options helps in discussing and planning important aspects of the end of life in advance and contributes to improved well-being among dying patients and their families.

Methods: Our study explores knowledge levels of EOL care and planning options and its sociodemographic and regional patterning using nationally representative data from respondents aged 55+ of wave 6 of the Survey of Health, Ageing and Retirement in Europe in Switzerland (n = 2,199).

Results: Respondents answered correctly on average to just under four out of eight questions regarding EOL care options. Women, individuals with higher education levels, and those living with a partner showed a higher EOL knowledge score, whereas the score is lower among older adults (75+) and individuals living in French- and Italian-speaking Switzerland.

Conclusion: In view of the significant EOL knowledge gaps among older adults in Switzerland, further education efforts on EOL care options are needed, with particular attention to the population groups most affected.

Dimensions of end-of-life preferences in the Swiss general population aged 55+

BACKGROUND

understanding end-of-life preferences in the general population and how they are structured in people's minds is essential to inform how to better shape healthcare services in accordance with population expectations for their end of life and optimise communication on end-of-life care issues.

OBJECTIVE

explore key dimensions underlying end-of-life preferences in a nationally representative sample of adults aged 55 and over in Switzerland.

METHODS

respondents (n = 2,514) to the Swiss version of the Survey of Health, Ageing and Retirement in Europe assessed the importance of 23 end-of-life items on a 4-point Likert scale. The factorial structure of the underlying end-of-life preferences was examined using exploratory structural equation modelling.

RESULTS

four dimensions underlying end-of-life preferences were identified: a medical dimension including aspects related to pain management and the maintenance of physical and cognitive abilities; a psychosocial dimension encompassing aspects related to social and spiritual support; a control dimension addressing the need to achieve some control and to put things in order before death; and a burden dimension reflecting wishes not to be a burden to others and to feel useful to others.

CONCLUSION

highlighting the multi-dimensionality of end-of-life preferences, our results reaffirm the importance of a holistic and comprehensive approach to the end of life. Our results also provide a general framework that may guide the development of information and awareness campaigns on end-of-life care issues in the general population, informational materials and guidelines to support healthy individuals in end-of-life thinking and planning, and advance directive templates appropriate for healthy individuals.

[Identifying patients in need of general or specialised palliative care with ID-PALL]

Palliative care is frequently associated with end of life and cancer, both in the general population and among healthcare professionals. ID-PALL is a new, short, easy-to-use instrument to help professionals to identify general or specialized palliative care needs in adult inpatients in different care settings. ID-PALL has already been validated in internal medicine units. ID-PALL should help professionals to discuss a suitable palliative care project, in order to maintain the best quality of life for patients and their relatives, and to involve palliative care specialists at the appropriate time. Recommendations for clinical practice are also proposed to guide professionals after the identification phase.

Participatory Development of a Modular Advance Care Planning Program in Pediatric Palliative Care (MAPPS)

CONTEXT

Decision-making in pediatric palliative care concerns mainly children without decision-making capacity. It has to balance the child's best interests, parental responsibility and the impact on the family system.

OBJECTIVES

Advance care planning (ACP) supports decision making about future medical care. A consistent pediatric approach is still missing. This study aimed at developing a pediatric ACP program (pedACP) meeting specific needs of children, parents and professionals.

METHODS

Bereaved parents of children with life-limiting conditions and professionals involved in pedACP participated. Employing the technique of constellation analysis, they collaboratively assigned content, actors, tools and warning notes about pedACP along a timeline. The researchers analyzed, systematized and translated these results into a pedACP program draft, which was revised by the participants.

RESULTS

The participants' overall focus was on the children's quality of life and an individualized interdisciplinary communication process along the disease trajectory. The program was conceptualized in modular design with fixed modules at the beginning (to build a trustful relationship and frame the process) and at the end (to summarize results and prepare implementation). The main discussions are structured in flexible modules (About the child, Emergencies, Disease-specific scenarios and End of life care). General themes cover timing, communication, engaging children and structural issues. The participants appreciated the program's comprehensiveness and flexibility.

CONCLUSION

Parents and professionals combined their perspectives on reflecting goals of care and the complexity of pedACP. They perceived the resulting modular program as suitable for meeting the individual needs of patients, families and professional stakeholders.

Instruments for the identification of patients in need of palliative care in the hospital setting: a systematic review of measurement properties

OBJECTIVE

The objective of this review was to provide a comprehensive overview of the measurement properties of the available instruments used by clinicians for identifying adults in need of general or specialized palliative care in hospital settings.

INTRODUCTION

Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging.

INCLUSION CRITERIA

We included development and validation studies that reported on measurement properties (eg, content validity, reliability, or responsiveness) of instruments used by clinicians for identifying adult patients (>18 years and older) in need of palliative care in hospital settings.

METHODS

Studies published until March 2020 were searched in four databases: Embase.com, Medline Ovid, PubMed, and CINAHL EBSCO. Unpublished studies were searched in Google Scholar, government websites, hospice websites, the Library Network of Western Switzerland, and WorldCat. The search was not restricted by language; however, only studies published in English or French were eligible for inclusion. The title and abstracts of the studies were screened by two independent reviewers against the inclusion criteria. Full-text studies were reviewed for inclusion by two independent reviewers. The quality of the measurement properties of all included studies were assessed independently by two reviewers according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

RESULTS

Out of the 23 instruments identified, four instruments were included, as reported in six studies: the Center to Advance Palliative Care (CAPC) criteria, the Necesidades Paliativas (NECPAL), the Palliative Care Screening Tool (PCST), and the Supportive and Palliative Care Indicators Tool (SPICT). The overall psychometric quality of all four instruments was insufficient according to the COSMIN criteria, with the main deficit being poor construct description during development.

CONCLUSIONS

For the early identification of patients needing palliative care in hospital settings, there is poor quality and incomplete evidence according to the COSMIN criteria for the four available instruments. This review highlights the need for further development of the construct being measured. This may be done by conducting additional studies on these instruments or by developing a new instrument for the identification of patients in need of palliative care that addresses the current gaps in construct and structural validity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020150074.

How to Open the Door: A Qualitative, Observational Study on Initiating Advance Care Discussions with Parents in Pediatric Palliative Care

Context: Advance care discussions (ACD) between health care professionals (HCPs) and parents of children with a life-limiting disease are a core element of successful pediatric advance care planning (pACP). Yet, they are perceived as a challenging situation for all participants. Objectives: Our goal was to investigate the first step of ACD and identify its challenges and helpful communication strategies to develop a conversation guide for initiating the pACP process and structure the conversational opening. Methods: We performed a participant observation of 11 initial ACD and 24 interviews with 13 HCPs and 20 parents of 11 children cared for by 3 different palliative care teams in southern Germany. Qualitative data collection was supplemented by a questionnaire. Content analysis and conversation analysis were used for evaluation. Results: Parents and HCPs start the process with different expectations, which can lead to misunderstandings and confusion. HCPs gain parental cooperation when they express the purpose of the meeting clearly and early, provide structure and guidance, and give parents time to talk about their experiences and feelings. Addressing dying and death is hard for both sides and requires a sensitive approach. Conclusions: Initiating ACD is extremely challenging for all participants. HCPs and parents should clarify expectations and aims at the beginning of the conversation. Future research should focus on how HCPs can be trained for this task and how the right timing for introducing ACD to families can be identified. Clinical Trial Registration number 049-12.

Will to Live in Older Nursing Home Residents: A Cross-Sectional Study in Switzerland

CONTEXT

The will to live (WTL) is an important indicator of subjective well-being. It may enable a deeper understanding of the well-being of nursing home residents.

OBJECTIVES

To evaluate the intensity of WTL, its association with various factors, and its temporal evolution among residents ≥ 65 years old; we also aimed to compare it with proxy assessments of WTL.

METHODS

A cross-sectional study was conducted in five nursing homes in Switzerland. Participants with decisional capacity were asked to rate the intensity of their WTL on a single-item numerical rating scale ranging from 0-10. A short-term follow-up was conducted among a sub-sample of 17 participants after three and six weeks. Proxy assessment by residents' next of kin and professional caregivers was conducted, and inter-rater agreement was calculated.

RESULTS

Data from 103 participants (75.7% women, 87.3 ± 8.0 years) was analyzed. The median intensity of WTL was 8. Higher WTL was significantly associated with better physical mobility and shorter duration of daily care but not with age, gender, pre-admission care setting, or prognosis. Significant independent predictors of WTL were physical mobility and provenance from rehabilitative care. In the short-term follow-up assessment, WTL remained highly stable. Intraclass correlation coefficients were moderate for residents' next of kin and nurse assistants but poor for physicians and nurses; all proxy assessments underestimated the participants' WTL.

CONCLUSION

Nursing home residents expressed a very strong WTL and proxy aents underestimated residents' WTL. It seems pivotal to proactively communicate with residents about their WTL.

ID-PALL: An Instrument to Help You Identify Patients in Need of Palliative Care

Palliative care is frequently associated with the end of life and cancer. However, other patients may need palliative care, and this need may be present earlier in the disease trajectory. It is therefore essential to identify at the right time patients who need palliative care and to distinguish between those in need of general palliative care and those for whom a referral to specialists is required. ID-PALL has been developed as an instrument to support professionals in this identification and to discuss a suitable palliative care project, in order to maintain the best quality of life for patients and their relatives. Recommendations for clinical practice are also proposed to guide professionals after the identification phase.

Goal-Concordant Care After Severe Acute Brain Injury

Background: Patients with severe acute brain injury (SABI) lack decision-making capacity, calling on families and clinicians to make goal-concordant decisions, aligning treatment with patient's presumed goals-of-care. Using the family perspective, this study aimed to (1) compare patient's goals-of-care with the care they were receiving in the acute setting, (2) identify patient and family characteristics associated with goal-concordant care, and (3) assess goals-of-care 6 months after SABI.

Methods: Our cohort included patients with SABI in our Neuro-ICU and a Glasgow Coma Scale Score <12 after day 2. Socio-demographic and clinical characteristics were collected through surveys and chart review. At enrollment and again at 6 months, each family was asked if the patient would prefer medical care focused on extending life vs. care focused on comfort and quality of life, and what care the patient is currently receiving. We used multivariate regression to examine the characteristics associated with (a) prioritized goals (comfort/extending life/unsure) and (b) goal concordance.

Results: Among 214 patients, families reported patients' goals-of-care to be extending life in 118 cases (55%), comfort in 71 (33%), and unsure for 25 (12%), while care received focused on extending life in 165 cases (77%), on comfort in 23 (11%) and families were unsure in 16 (7%). In a nominal regression model, prioritizing comfort over extending life was significantly associated with being non-Hispanic White and having worse clinical severity. Most patients who prioritized extending life were receiving family-reported goal-concordant care (88%, 104/118), while most of those who prioritized comfort were receiving goal-discordant care (73%, 52/71). The only independent association for goal concordance was having a presumed goal of extending life at enrollment (OR 23.62, 95% CI 10.19–54.77). Among survivors at 6 months, 1 in 4 family members were unsure about the patient's goals-of-care.

Conclusion: A substantial proportion of patients are receiving unwanted aggressive care in the acute setting after SABI. In the first days, such aggressive care might be justified by prognostic uncertainty. The high rate of families unsure of patient's goals-of-care at 6 months suggests an important need for periodic re-evaluation of prognosis and goals-of-care in the post-acute setting.

Measurement Properties of ID-PALL, A New Instrument for the Identification of Patients With General and Specialized Palliative Care Needs

CONTEXT

To improve access to palliative care, identification of patients in need of general or specialized palliative care is necessary. To our knowledge, no available identification instrument makes this distinction. ID-PALL is a screening instrument developed to differentiate between these patient groups.

OBJECTIVE

To assess the structural and criterion validity and the inter-rater agreement of ID-PALL.

METHODS

In this multicenter, prospective, cross-sectional study, nurses and physicians assessed medical patients hospitalized for 2 to 5 days in two tertiary hospitals in Switzerland using ID-PALL. For the criterion validity, these assessments were compared to a clinical gold standard evaluation performed by palliative care specialists. Structural validity, internal consistency and inter-rater agreement were assessed.

RESULTS

2232 patients were assessed between January and December 2018, 97% by nurses and 50% by physicians. The variances for ID-PALL G and S are explained by two factors, the first one explaining most of the variance in both cases. For ID-PALL G, sensitivity ranged between 0.80 and 0.87 and specificity between 0.56 and 0.59. ID-PALL S sensitivity ranged between 0.82 and 0.94, and specificity between 0.35 and 0.64. A cut-off value of 1 delivered the optimal values for patient identification. Cronbach's alpha was 0.78 for ID-PALL G and 0.67 for ID-PALL S. The agreement rate between nurses and physicians was 71.5% for ID-PALL G and 64.6% for ID-PALL S.

CONCLUSION

ID-PALL is a promising screening instrument allowing the early identification of patients in need of general or specialized palliative care. It can be used by nurses and physicians without a specialized palliative care training. Further testing of the finalized clinical version appears warranted.

Instruments for the identification of patients in need of palliative care: protocol for a systematic review of measurement properties

OBJECTIVE

The objective of this review is to provide a comprehensive overview of the psychometric properties of available clinician-reported instruments developed to identify patients in need of general and specialized palliative care in acute care settings.

INTRODUCTION

Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging. To our knowledge, no dedicated instruments are available to date to assist health care professionals to make this identification.

INCLUSION CRITERIA

Included studies will report on i) instruments aiming to identify patients in need of palliative care, ii) adult patients in need of palliative care in acute-care settings, iii) clinician-reported outcome measures, or iv) the development process or one or more of its measurement properties. Studies conducted in intensive care units, emergency departments, or nursing homes will be excluded.

METHODS

We will search for studies published in English and French in a variety of sources, including Embase, Medline Ovid SP, PubMed, CINAHL EBSCO, Google Scholar, government websites, and hospice websites. All citations will be screened and selected by two independent reviewers. Data extraction, quality assessment, and syntheses of included studies will be performed according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020150074.

Assessing the Will to Live: A Scoping Review

CONTEXT

The will to live (WTL) is an important factor to consider in the context of providing resource-oriented palliative care. Until now, there has been no major review of the existing research on this subject.

OBJECTIVES

The primary objective of this study is to summarize the state of research concerning instruments that assess the WTL. The secondary objective is to explore the theoretical models and psychometric properties of these instruments, in studies where these instruments were initially presented. The tertiary objective is to identify, among all studies where these instruments have been used, the intensity of the WTL, and factors associated with it.

METHODS

We conducted a scoping review, including studies that were designed to assess the WTL among participants in all settings. Records were systematically searched from seven bibliographic databases with no date limitations up to August 2020.

RESULTS

Of the 3078 records screened, 281 were examined in detail and 111 were included in the synthesis. A total of 25 different instruments quantitatively assessing the WTL are presented. Most are single-question tools and rate intensity. The underlying concepts and psychometric properties are incompletely explained. Lack of crossreferencing is apparent. The intensity of the WTL is high, even among people with significant health impairment, and is frequently associated with different factors, such as resilience and quality of life.

CONCLUSION

A considerable yet unconnected body of studies assesses the WTL. Its assessment in clinical routine could promote resource-oriented and patient-centered care.

Views on a "Good Death": End-of-Life Preferences and Their Association With Socio-Demographic Characteristics in a Representative Sample of Older Adults in Switzerland

The current study explores the end-of-life (EOL) preferences of a national representative sample of adults aged 55 and older in Switzerland and shows how these preferences vary by respondents' sociodemographic characteristics and the linguistic region in which they live. Many of the presented EOL attributes are considered as (very) important by a large majority of the older population in Switzerland with significant variations across sociodemographic groups. Specifically, gender is related to psychosocial aspects of EOL, age to the importance attached to avoiding being a burden on the society, and education levels to preferences regarding overtreatment and advance care planning. The results highlight the importance of a personalized, holistic and interdisciplinary approach to EOL and EOL care, since social, psychological, organizational and physical aspects of EOL are rated as (very) important with significant differences in EOL preferences across sociodemographic groups.

Current collaboration between palliative care and neurology: a survey of clinicians in Europe

INTRODUCTION

The collaboration between palliative care and neurology has developed over the last 25 years and this study aimed to ascertain the collaboration between the specialties across Europe.

METHODS

This online survey aimed to look at collaboration across Europe, using the links of the European Association for Palliative Care and the European Academy of Neurology.

RESULTS

298 people completed the survey-178 from palliative care and 120 from neurology from over 20 countries across Europe. They reported that there was good collaboration in the care for people with amyotrophic lateral sclerosis and cerebral tumours but less for other progressive neurological diseases. The collaboration included joint meetings and clinics and telephone contacts. All felt that the collaboration was helpful, particularly for maintaining quality of life, physical symptom management, psychological support and complex decision making, including ethical issues.

DISCUSSION

The study shows evidence for collaboration between palliative care and neurology, but with the need to develop this for all neurological illness, and there is a need for increased education of both areas.

Meaning in life and quality of life: palliative care patients versus the general population

BACKGROUND AND OBJECTIVES

Meaning in life (MIL) represent a key topic in palliative care. The aims of this study were to explore (1) the differences in perceived MIL and in the meaning-relevant life areas between a representative sample of the Swiss population and palliative care patients, and (2) to what extent MIL can be considered as a significant predictor of quality of life (QOL).

METHODS

A cross-sectional study was conducted separately for the patients (face-to-face interviews) and the general population (telephone survey). MIL was measured with the Schedule for Meaning in Life Evaluation (SMILE) and QOL with a single-item visual analogue scale (0-10). Sociodemographic variables were controlled for in the analyses.

RESULTS

206 patients and 1015 participants from the Swiss population completed the protocol. Results indicated high MIL scores in both populations even if the difference was significant (patients 81.9 vs general population 87, p<0.001). Patients were more likely to cite 'family' (OR=1.78), 'social relations' (OR=1.9), 'spirituality and religion' (OR=3.93), 'social commitment' (OR=1.94) and 'growth' (OR=2.07), and less likely to cite 'finances' (OR=0.15) and 'health' (OR=0.21) as MIL-relevant areas. The SMILE scores and MIL areas explained 21.8% of the QOL variance for the patients and 15.1% for the representative sample.

CONCLUSIONS

Our data emphasise the importance of MIL as a contributor to QOL in both populations. It highlights the importance of the life areas contributing to MIL, especially social interactions for both populations, and spirituality and areas related to growth in palliative care patients.

Social, cultural and experiential patterning of attitudes and behaviour towards assisted suicide in Switzerland: evidence from a national population-based study

Switzerland has the longest history of the legal practice of non-physician assisted suicide of any country. Assisted suicide is not very tightly regulated in Switzerland, and almost all assisted suicides are supported by a right-to-die organisation. Our study investigates older adults&rsquo; attitudes and behaviour towards assisted suicide, and the associations of these with the individuals&rsquo; sociodemographic and cultural characteristics, as well as with their own health status and healthcare-related experiences in Switzerland. We performed weighted prevalence and multivariable logistic regression estimation on a nationally representative sample of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2168). Overall, 81.7% of respondents supported the legality of assisted suicide, as is currently the case in Switzerland, and 60.9% stated that they would potentially consider asking for assisted suicide under certain circumstances; 28.2% of respondents reported either that they are already or that they are likely to become a member of a right-to-die organisation, with 4.9% of respondents reporting to already be a member of such an organisation at the time of the survey. Higher levels of education and previous experience as a healthcare proxy were positively associated with more favourable attitudes and behaviour towards assisted suicide. Compared to individuals aged 55&ndash;64, adults aged 65&ndash;74 generally showed more favourable attitudes and behaviour towards assisted suicide. By contrast, religious persons displayed more negative attitudes and behaviour towards assisted suicide. Attitudes towards assisted suicide were also more negative in the oldest age group (75+) in comparison to adults aged 55&ndash;64, and among persons living in French- and Italian-speaking Switzerland compared to those living in German-speaking Switzerland. While approval for assisted suicide is high overall in Switzerland, more vulnerable population groups, such as older or less educated individuals, have less favourable attitudes towards assisted suicide. In addition, cultural sensitivities to and personal experiences with death and dying are likely to shape the approval or rejection of assisted suicide as it is currently implemented in Switzerland.

Associations of end-of-life preferences and trust in institutions with public support for assisted suicide: evidence from nationally representative survey data of older adults in Switzerland

The legality of euthanasia and assisted suicide (AS) and nature of regulations of these practices remain controversial and the subject of lively debate among experts and the general public. Our study investigates attitudes and behaviours towards AS among older adults in Switzerland where the practice of AS has a relatively long history and remains rather unregulated. We aim to explore how individuals' preferences regarding their end of life, as well as individuals' trust in institutions involved in the practice or control of AS are associated with attitudes and behaviours towards AS. We analyse nationally representative data of adults aged 55 and over from wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) in Switzerland (n = 2,145). While large majorities supported current legal arrangements around AS in Switzerland (81.7%) and stated that they could consider AS for themselves under certain circumstances (61.0%), only a minority either was a member of a right-to-die organisation already (4.9%) or stated they were likely to become a member of such an organisation (28.2%). Stated preferences for control over the end of life and for maintaining essential capabilities at the end of life showed a positive association with AS-related attitudes and behaviours, whereas preferences for feeling socially and spiritually connected, as well as for not being a burden displayed a negative association with our outcomes. Higher levels of trust in one's relative were positively associated with both support for the legality of AS and potential use of AS. A positive association was also found between trust in the Swiss legal system and support for the legality of AS. By contrast, trust in religious institutions displayed a negative association with all five AS-related attitudes and behaviours. Similarly, trust in healthcare insurance companies was negatively associated with potential use of AS. Taken together, older adults were generally supportive towards current practices regarding AS. This approval appears to be closely related to individuals' preferences and, at different extends, to trust in social and public institutions with regard to end-of-life issues, which is relatively high in Switzerland.

COVID-19: decision making and palliative care

Due to the current development around the COVID-19 pandemic, palliative ch has created a Task Force to provide recommendations for health professionals on the treatment of palliative care patients in the various settings ‒ inpatient and outpatient.

Identifying key elements for paediatric advance care planning with parents, healthcare providers and stakeholders: A qualitative study

BACKGROUND

Although international guidelines recommend discussions about goals of care and treatment options for children with severe and life-limiting conditions, there are still few structured models of paediatric advance care planning.

AIM

The study aimed at identifying key components of paediatric advance care planning through direct discussions with all involved parties.

DESIGN

The study had a qualitative design with a participatory approach. Participants constituted an advisory board and took part in two transdisciplinary workshops. Data were collected in discussion and dialogue groups and analysed using content analysis.

SETTING/PARTICIPANTS

We included bereaved parents, health care providers and stakeholders of care networks.

RESULTS

Key elements were discussions, documentation, implementation, timing and participation of children and adolescents. Parents engage in discussions with facilitators and persons of trust to reach a decision. Documentation constitutes the focus of professionals, who endorse brief recommendations for procedures in case of emergencies, supplemented by larger advance directives. Implementation hindrances include emotional barriers of stakeholders, disagreements between parents and professionals and difficulties with emergency services. Discussion timing should take into account parental readiness. The intervention should be repeated at regular intervals, considering emerging needs and increasing awareness of families over time. Involving children and adolescents in advance care planning remains a challenge.

CONCLUSION

A paediatric advance care planning intervention should take into account potential pitfalls and barriers including issues related to timing, potential conflicts between parents and professionals, ambiguity towards written advance directives, the role of non-medical carers for paediatric advance care planning implementation, the need to involve the child and the necessity of an iterative process.

Visualizing social support in home pediatric palliative care using network maps

BACKGROUND

Home care of children with life-limiting diseases is extremely challenging for parents/family caregivers and their social environment. In order to gain new insights into the perspective of family caregivers, we employed digital Network Maps for the first time in the field of pediatric palliative care.

AIM

To examine whether the use of Network Maps helps to identify and visualize significant members of the social support system and the quality of the relationship, as well as the main areas of life that are experienced as being supportive by each individual.

DESIGN

The design was an integrated mixed methods study. Creation of Network Maps was assessed in conjunction with qualitative interviews. In addition, participants gave an oral feedback on the Network Maps themselves.

SETTING/PARTICIPANTS

Parents of patients supported by a Specialized Home Pediatric Palliative Care team were eligible for inclusion. Forty-five parents were enrolled in the study.

RESULTS

All mothers and fathers were able to generate their individual Network Map without problems. The composition of the support systems differed greatly, even between members of the same family. Parents named on average 11 supporting actors, mainly family members and health care professionals. Some relationships were perceived as helpful and stressful at the same time.

CONCLUSION

Network Maps appear to be an appropriate tool for the collection, reconstruction, and assessment of the current support situation of parents of dying children. Further studies should examine the usefulness of Network Maps for the understanding of the caregivers' support needs and for the development of psychosocial interventional strategies by pediatric palliative care teams.

IDentification of patients in need of general and specialised PALLiative care (ID-PALL©): item generation, content and face validity of a new interprofessional screening instrument

BACKGROUND

Early identification of patients requiring palliative care is a major public health concern. A growing number of instruments exist to help professionals to identify these patients, however, thus far, none have been thoroughly assessed for criterion validity. In addition, no currently available instruments differentiate between patients in need of general vs. specialised palliative care, and most are primarily intended for use by physicians. This study aims to develop and rigorously validate a new interprofessional instrument allowing identification of patients in need of general vs specialised palliative care.

METHODS

The instrument development involved four steps: i) literature review to determine the concept to measure; ii) generation of a set of items; iii) review of the initial set of items by experts to establish the content validity; iv) administration of the items to a sample of the target population to establish face validity. We conducted a Delphi process with experts in palliative care to accomplish step 3 and sent a questionnaire to nurses and physicians non-specialised in palliative care to complete step 4. The study was conducted in the French and Italian-speaking regions of Switzerland. An interdisciplinary committee of clinical experts supervised all steps.

RESULTS

The literature review confirmed the necessity of distinguishing between general and specialised palliative care needs and of adapting clinical recommendations to these different needs. Thirty-six nurses and physicians participated in the Delphi process and 28 were involved in the face validity assessment. The Delphi process resulted in two lists: a 7-item list to identify patients in need of general PC and an 8-item list to identify specialised PC needs. The content and face validity were deemed to be acceptable by both the expert and target populations.

CONCLUSION

This instrument makes a significant contribution to the identification of patients with palliative care needs as it has been designed to differentiate between general and specialised palliative care needs. Moreover, diagnostic data is not fundamental to the use of the instrument, thus facilitating its use by healthcare professionals other than physicians, in particular nurses. Internal and criterion validity assessments are ongoing and essential before wider dissemination of the instrument.

Validation of the French Version of the Integrated Palliative Care Outcome Scale

CONTEXT

The Integrated Palliative care Outcome Scale (IPOS) is a widely used tool for assessing patient needs in palliative care.

OBJECTIVES

The aim of this study was to provide a validated version of the patient and staff IPOS for French-speaking Switzerland (IPOS-Fr) and assess its psychometric properties.

METHODS

The validation took place in 12 palliative care units and mobile teams. At baseline (T1) and three days later (T2), patients' general health status, palliative care needs (IPOS-Fr), and quality of life (McGill Quality of Life Scale-Revised) were assessed by patients and staff.

RESULTS

We included 173 patients (mean age: 68.8; 92 women; 85% oncologic disease). IPOS internal consistency was high for the total score (0.69 and 0.71). Staff-patient interrater agreement was good to moderate for 13 items (intraclass correlations >0.516). Results indicated strong correlations between IPOS-Fr and McGill Quality of Life Scale-Revised for the total score (-0.623 at T1) and the psychological domain (Item 11: -0.601 at T1; Item 13: -0.633 at T2). Regarding sensitivity to change, there was a significant difference between T1 and T2 for patients with an improved health condition (z = -2.326; P = 0.020).

CONCLUSION

IPOS-Fr has fair to good validity, especially with regard to interrater agreement and construct validity, is sensitive to positive change, and has good interpretability and acceptability for patients and staff. IPOS-Fr is not optimal in terms of internal consistency and structure when using subscale scores, except for the emotional subscale.

Perinatal Palliative Care: A qualitative study evaluating the perspectives of pregnancy counselors

BACKGROUND

A prenatal diagnosis of a life-limiting disease raises complex ethical, emotional, and medical issues. Studies suggest that 40%-85% of parents decide to continue the pregnancy if given the option of Perinatal Palliative Care. However, structured Perinatal Palliative Care programs are missing in many European countries. In Germany, parents have the right to free psychosocial support from pregnancy counseling services after the prenatal diagnosis of a life-limiting disease.

AIM

We aimed to investigate whether German professional pregnancy counselors perceive the need for structured Perinatal Palliative Care and if so, how it should be conceived.

DESIGN

This is a qualitative interview study with purposeful sampling. The interviews were analyzed with the coding method of Saldaña.

SETTING/PARTICIPANTS

A total of 10 professionals from three different pregnancy counseling services participated in the study.

RESULTS

The main topics raised by the professionals were as follows: (1) counseling and parental support during the decision-making process; (2) fragmented or missing support infrastructure for parents; and (3) challenges, hesitations, and barriers, particularly from the different stakeholders, regarding a Perinatal Palliative Care framework. They highlighted the importance of the integration of Perinatal Palliative Care in existing structures, a multi-professional approach, continuous coordination of care and education for all healthcare providers involved.

CONCLUSION

A structured Perinatal Palliative Care program is considered as necessary by the pregnancy counselors. Future research should focus on (1) needs reported by concerned parents; (2) attitude and role of all healthcare providers involved; (3) strategies to include stakeholders in the development of Perinatal Palliative Care networks; and (4) outcome parameters for evaluation of Perinatal Palliative Care frameworks.

Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis

OBJECTIVE

This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes.

METHODS

We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD.

RESULTS

50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only.

CONCLUSION

ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.