Measuring decision aid effectiveness for end-of-life care: A systematic review

Objective

To systematically review research analyzing the effectiveness of decision aids for end-of-life care, including how researchers specifically measure decision aid success.

Methods

We conducted a systematic review synthesizing quantitative, qualitative, and mixed-methods study results using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases were searched through February 18, 2023. Inclusion criteria required articles to evaluate end-of-life care decision aids. The review is registered under PROSPERO (#CRD42023408449).

Results

A total of 715 articles were initially identified, with 43 meeting the inclusion criteria. Outcome measures identified included decisional conflict, less aggressive care desired, knowledge improvements, communication improvements, tool satisfaction, patient anxiety and well-being, and less aggressive care action completed. The majority of studies reported positive outcomes especially when the decision aid development included International Patient Decision Aid Standards.

Conclusion

Research examining end of life care decision aid use consistently reports positive outcomes.

Innovation

This review presents data that can guide the next generation of decision aids for end-of-life care, namely using the International Patient Decision Aid Standards in developing tools and showing which tools are effective for helping to prevent the unnecessary suffering that can result when patients' dying preferences are unknown.

Questions From Family Members During the Dying Process And Moral Distress Experienced by ICU Nurses

BACKGROUND

For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family.

OBJECTIVE

To examine the experiences of ICU nurses caring for patients receiving CMO.

METHODS

Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress.

RESULTS

Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress.

CONCLUSION

There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress.

Knowledge and attitudes of medical students toward death: a cross-sectional comparative study between an Arab and a Western University

BACKGROUND

Cultural factors influence attitudes toward death, and gender disparities are evident. Prior studies show that medical students have limited knowledge about death and are uncomfortable with it. Moreover, there is limited research that has examined factors that influence medical students' knowledge and attitudes toward death.

OBJECTIVES

The objectives of the study were to compare cultural and gender differences in relation to knowledge and attitudes toward loss and grief and to screen for complicated grief among medical students at the Arabian Gulf University and the University of Toronto.

METHODS

A cross-sectional study was disseminated to medical students at both universities in 2022. The variables in the survey included four parts: demographic characteristics of the participants, religious observance, history of encountering loss of a loved one, grief following loss, attitude toward death, and learning about how to deal with grief and death during medical school. The brief grief questionnaire and the death attitude profile-revised scales were used.

RESULTS

The study sample consisted of 168 medical students, with 74.1% being female. Complicated grief scores were higher among Arabian Gulf University students (3.87 ± 2.39) than among University of Toronto students (2.00 ± 1.93) and were higher for participants with a higher degree of religious observance in both schools (p < 0.05). Death avoidance (p = 0.003), approach acceptance (p < 0.001), and escape acceptance (p = 0.038) domains were significantly higher among Arabian Gulf University students than among University of Toronto students. Almost three-quarters of University of Toronto students reported not being taught about grief, compared to 54% of Arabian Gulf University students.

CONCLUSIONS

Arabian Gulf University medical students scored higher on complicated grief, most likely due to cultural and religious factors. Females at both institutions as well as those who indicated a higher level of religious observance reported higher scores of complicated grief. The study highlights how cultural and religious beliefs influence medical students' attitudes toward death and bereavement. It provides valuable insight into the knowledge and attitudes of medical students toward loss.

First and final farewells, disrupted family connections and loss: A collective case study exploring the impact of COVID-19 visitor restrictions in critical care

BACKGROUND

Patient and family-centred care is considered best practice. Such an approach is associated with high quality and positive experiences of care, and family presence at the bedside is encouraged and enabled. The COVID-19 pandemic, however, resulted in strictly enforced restrictions on hospital visitation, which threatened health professionals' ability to provide family-centred care.

AIM

To explore the impact of COVID-19 visitor restrictions on family relationships during critical illness at the end of life in the intensive care unit.

DESIGN

A retrospective collective case study approach was taken, using semi-structured interviews, conducted via telephone or Zoom, in accordance with COVID-19 restrictions.

SETTING/PARTICIPANTS

Two participant groups, bereaved next-of-kin of patients who died in the intensive care unit (n = 6) and critical care nurses (n = 3) from a major metropolitan hospital were included.

FINDINGS

Interviews with bereaved next-of-kin lasted 25-59 (mean = 41) minutes, and critical care nurse interviews lasted 31-52 (mean = 43) minutes. Inductive content analysis revealed five themes: (i) the first farewell, the significance not realised at the time; (ii) confusing rules and restrictions, which emphasised physical and created emotional barriers to family connections; (iii) inadequate communication, which further impacted next-of-kin; (iv) final farewells, which were rushed, emotional and afforded no privacy; and (v) reflecting back.

CONCLUSIONS

This collective case study demonstrates the profound impact visitor restrictions have had on bereaved next-of-kin and the wider family. A family-centred approach to care, protecting and prioritising family connection, and recognising the patient as a person who is part of a larger family unit must be emphasised.

IMPLICATIONS FOR CLINICAL PRACTICE

Critical care teams must consider their own approach to end-of-life care during times of visitor restrictions, finding new, flexible and innovative ways to improve communication, promote family-centred care, maintain the patient-family connection and facilitate end-of-life cultural customs, and rituals imperative to next-of-kin and the wider family unit.

Māori end-of-life care in the intensive care unit: A qualitative exploration of nursing perspectives

BACKGROUND

Although goals of care for intensive care patients are typically focussed on restoration of health, 8-15% of patients will die in the intensive care unit (ICU), or soon after transfer to a ward. Early recognition of the need for end-of-life care is vital to identify and support the wishes of the patient and needs of their family. In Aotearoa, New Zealand, Māori are over-represented in admissions to ICUs. Enabling nursing staff to provide culturally safe care to Māori patients and whānau (family, including extended family, kin) at the end of life is critical to upholding Te Tiriti o Waitangi requirements and providing equitable care. This qualitative study explores the experiences of both Māori and non-Māori intensive care nurses, in providing end-of-life care for Māori patients and their whānau.

OBJECTIVES

The objective of this study was to characterise nursing experiences of end-of-life care for Māori in the ICU, identify barriers to and facilitators of confident, competent culturally responsive care, and highlight opportunities to improve preparation and support.

METHODS

Qualitative semistructured interviews were undertaken with nine intensive care nurses (four Māori and five non-Māori) with experience ranging from novice to expert. Data collection and analysis was underpinned by reflexive thematic analysis strengthened by Kaupapa Māori Research values and tikanga best practice.

FINDINGS

Participants described positive and negative experiences in caring for Māori at the end of life. Culturally responsive end-of-life care for Māori in intensive care appears dependent on the acknowledgement and inclusion of whānau as members of the multidisciplinary team. Participants identified a need for high-quality education, supportive unit end-of-life care guidelines and hospital policies, and cultural resources to confidently provide quality end-of-life care.

CONCLUSION

Improved understanding of Māori culture, critical awareness of systems of power and privilege, and the availability of cultural liaisons may increase the confidence and competence of ICU nurses providing care to Māori whānau.

Facing uncertainty - Pilot testing of a palliative prognostic index training with hospital aged care assessment teams

BACKGROUND

Prognostic avoidance can delay discussions about older hospital patients' life expectancy. This pilot study examined the effects of a prognostic training program on hospital clinicians' knowledge and confidence in identifying older patients at risk of dying.

METHODS

Fifty-seven clinicians from aged care assessment teams at two Australian hospitals were introduced to the Palliative Prognostic Index, a 5-item checklist indicating prognoses between 3 and 6 weeks. Mixed-methods training evaluation included pre-post-training surveys and semi-structured interviews, conducted three months post-training.

RESULTS

Clinicians used a combination of experience, knowledge, and intuition as strategies to generate prognoses. Allied health staff relied on intuition more often than medical and nursing staff. Prognostic tools were rarely used. Pre-post-training comparisons showed significant improvements in clinicians' knowledge and confidence in identifying signs of dying, particularly amongst allied health. Follow-up interviews highlighted advantages and challenges of using prognostic tools. Recommendations are made for addressing these.

The relationship between moral distress, ethical climate, and attitudes towards care of a dying neonate among NICU nurses

BACKGROUND

Nurses working in neonatal intensive care units play a crucial role in providing care to critically ill or premature neonates. However, is not without its challenges, particularly when it comes to making difficult ethical decisions about end-of-life care. In some cases, neonates do not survive despite the best efforts of medical professionals. The present study aimed to investigate the relationship between moral distress, ethical climate, and attitudes towards end-of-life care among nurses working in neonatal intensive care units.

METHODS

This is a descriptive-analytical cross-sectional study (May 21, 2021).The research population included 126 nurses working in neonatal intensive care units in Kerman province (Kerman, Jiroft, Bam, and Rafsanjan). Data collection tools included four questionnaires: demographic information, the Frommelt Attitudes towards Care of the Dying (FATCOD), the Hospital Ethical Climate Survey, and the Moral Distress Scale. SPSS22 was used to analyze the data.

RESULTS

The results revealed that the mean frequency and intensity of moral distress were 44.42 ± 17.67 and 49.45 ± 17.11, respectively. The mean ethical climate was 92.21 ± 17.52 and the FATCOD was 89.75 ± 9.08, indicating NICU nurses' positive perceptions of ethical climate and their favorable attitudes towards EOL care, respectively. The results showed a direct and significant relationship between ethical climate and the FATCOD (P = 0.003, r = 0.26).

DISCUSSION

We suggest policymakers and managers design strategies for better ethical climate in hospitals and reduction of moral distress among nurses.

"Time and life is fragile": An integrative review of nurses' experiences after patient death in adult critical care

INTRODUCTION

Providing bereavement support and care to families is an aspect of critical care nursing practice that can be rewarding, yet emotionally and psychologically challenging. Whilst significant research has focused on end-of-life care in critical care, less is known about nurses' experiences after patient death.

AIM

The aim of this study was to synthesise research evidence on the experience of registered nurses after patient death in adult critical care.

DESIGN

A structured integrative review of the empirical literature was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Cumulative Index Nursing and Allied Health Literature (CINAHL) Complete, Ovid Medline, PsycInfo, Embase, and Emcare databases. Records were independently assessed against inclusion and exclusion criteria. A process of forward and backward chaining was used to identify additional papers. All papers were assessed for quality. Narrative synthesis was used to analyse and present the findings.

RESULTS

From the 4643 records eligible for screening, 36 papers reporting 35 studies were included in this review, representing the voices of 1687 nurses from more than 20 countries. Narrative synthesis revealed three themes: (i) postmortem care, which encompassed demonstrating respect and dignity for the deceased, preparation of the deceased, and the concurrent death rituals performed by nurses; (ii) critical care nurses' support of bereaved families, including families of potential organ donors and the system pressures that impeded family support; and (iii) nurses' emotional response to patient death including coping mechanisms.

CONCLUSIONS

Whilst a focus on the provision of high-quality end-of-life care should always remain a priority in critical care nursing, recognising the importance of after-death care for the patient, family and self is equally important. Acknowledging their experience, access to formal education and experiential learning and formal and informal supports to aid self-care are imperative.

Intentional presence and the accompaniment of dying patients

In this paper, we offer a phenomenological and hermeneutical perspective on the presence of clinicians who care for the suffering and dying patients in the context of end-of-life care. Clinician presence is described as a way of (1) being present to the patient and to oneself, (2) being in the present moment, and (3) receiving and giving a presence (in the sense of a gift). We discuss how presence is a way of restoring human beings' relational and dialogical nature. To inform a different perspective on relational ethics, we also discuss how accompaniment refers to the clinician's awareness of the human condition and its existential limits.

The Emmaus Project: Aging, Illness, and Dying Among Older Christians-A Qualitative Study

Older patients have an increased risk of depression, neglect, and abuse. Studies demonstrate that spiritual and religious coping is important at times of personal crisis, but few studies explore the impact of religion on older persons' experiences of aging, illness, and impending death. This study set out to identify recurring spiritual and clinical themes shared by retirement home residents in the context of a Christian faith-based processing group. A qualitative cohort study of residents over the age of 65 was conducted at a retirement home in Chicago, Illinois. The study consisted of 8 hour-long Scripture-based processing group sessions co-led by a study researcher and the onsite chaplain. Questionnaires were administered to each group and handwritten responses were collected and analyzed to identify recurring clinical and spiritual themes. Ten participants enrolled in the group study. The questionnaire completion rate was 35% (49/140). The most recurring clinical themes included 1) events of death or terminal illness and 2) physical limitations. The most recurring spiritual themes included 1) God's presence and 2) prayer and worship. The most recurring coded theme overall was family. This study provided insight into the spiritual experiences of older Christians in one retirement home community. Increased awareness of the spiritual perspectives of the geriatric population may strengthen the doctor-patient relationship and lead to improvements in clinical care.

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.

Social relations and exclusion among people facing death

In line with current policies and service developments related to palliative care, more people are dying at home. This situation has provoked discussions about the importance of non-medical issues related to death. The process of dying is often long, with many phases, and the social aspect is a major part of it. Our focus in this article is on dying as a social process. Social relationships are significant and play a meaningful role in enhancing the well-being of older adults approaching the end of life. Meaningful social relationships tend to change over time; however, and the process of dying may exacerbate such changes in and challenge these relationships. The aim of our study was to examine how social relationships are experienced and (re)constructed among older adults (70-83 years old) during the process of dying, in a Finnish context. We were interested in the nature and type of these relationships, and in the possible new forms of expression that may emerge during this process. Our empirical data were based on interviews with seven older adults who were close to death. The analysis revealed processes of exclusion from existing relations. At the same time, we observed new and unexpected relations being initiated, which sometimes became meaningful and supportive. The results highlighted the role of expectations and importance of analysing exclusion from a life-course perspective.

Judaism

Judaism offers a rich body of traditional beliefs and practices surrounding end-of-life, death, mourning, and the afterlife. A more detailed understanding of these topics might prove helpful to clinicians seeking guidance for how best to care for Jewish patients, to anyone supporting dying individuals, or to anyone interested in learning more about the subject. The objectives of this chapter are to examine Jewish approaches to key bioethical issues surrounding palliative care, to analyze meaning-making rituals following a loss, at a funeral, and throughout mourning, and to explore Jewish beliefs in an afterlife. Research was collected from sacred texts, legal codes, modern rabbinic responsa literature, and secondary sources. Core, guiding principles include human beings' creation "in the image of God," an obligation to save life, an obligation to mitigate pain, a prohibition against self-harm and hastening death, respect for the dead, and ritualized mourning periods ("shiva," "shloshim," and "shanah"), which feature special liturgy ("kaddish") and practices. Judaism is a religion that values thorough questioning, debate, and argumentation. It also encompasses diverse cultural and ethnic backgrounds, and various denominations. Many Jews are also unaffiliated with a movement or rarely engage with traditional law altogether. For all of these reasons, no summary can comprehensively encapsulate the wide range of opinions that exist around any given topic. That said, what follows is a detailed overview of traditional Jewish approaches to artificial nutrition/hydration, extubation, dialysis, euthanasia and more. It also outlines rituals surrounding and following death. Finally, views and beliefs of the afterlife are presented, as they often serve to imbue meaning and comfort in times of grief, uncertainty, and transition.

Cancer, Religious Philosophy, Death and Dying

This final issue of JORH for 2022 revisits the topics of (1) cancer, (2) religious philosophy, and (3) uniquely collates a number of papers discussing the theme of death and dying-which seems an appropriate topic given the conclusion and celebration of life for one of the most internationally admired monarchs, Queen Elizabeth II (1926-2022). Lastly a call for papers is issued regarding religion, spirituality, suicide, and its prevention: https://www.springer.com/journal/10943/updates/23471166 .

When cultural values meets professional values: a qualitative study of chinese nurses' attitudes and experiences concerning death

Background

In China, there is a culture of death-avoidance and death-denying. Influenced by this distinctive socio-cultural views surrounding death, nurses often find it challenging to handle death and care for dying patients. This study explores the nurses’ attitudes and coping strategies concerning death and caring for dying patients in a cultural context of death taboo.

Methods

This research is a qualitative study that employs in-depth, semi-structured interviews with nurses from two major hospitals in Guangzhou, China. Overall, 28 nurses from four departments with high patient death rate were recruited and interviewed. All of the interviews were analyzed thematically.

Results

The nurses who participated in this study expressed attitudes toward death and caring for dying patients from both a personal dimension and a professional dimension. The personal dimension is influenced by traditional culture and societal attitudes towards death and dying, while their professional dimension is congruent with the nursing and palliative care values concerning death and dying. With an obvious discrepancy between these two dimensions, Chinese nurses adopt three strategies in their practice to solve this tension: boundary-drawing to separate their personal and professional life, complying with the existing cultural values at work, and constructing positive meanings for end-of-life care.

Conclusion

In a society that traditionally avoids making any reference to death, it is useful to reduce cultural taboo and construct positive meanings in end-of-life care, death education and the development of palliative care. Meanwhile, nurses also need institutional support, education and training to transition smoothly from a novice to a mature professional when handling patient death.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01067-3.

How do intensive care clinicians ensure culturally sensitive care for family members at the end of life? A retrospective descriptive study

INTRODUCTION

Patients and their family members have diverse needs at the end of life, influenced by culture.

OBJECTIVE

To examine whether clinicians (doctors and nurses), provided culturally sensitive care for family members of patients from culturally diverse backgrounds who died in an intensive care unit.

METHODS

A retrospective medical record audit was undertaken in four metropolitan intensive care units in Melbourne, Australia. Quantitative data are reported using descriptive statistics. Qualitative progress note entries are presented using themes.

RESULTS

In all, 430 patients died in 2018 and were included in the audit. Almost half of patients (47.9%, n = 206) were born in Australia, with the remaining 52.1% (n = 224) representing 41 other countries of birth. Languages other than English were spoken by 14.9% (n = 64) of patients. Christian religions were most common (50.2%, n = 216), followed by Buddhism 3.0% (n = 13), and Hindu and Islam respectively (1.9%, n = 8). A cultural assessment was undertaken in 10.5% (n = 45) of cases, mostly by social workers, to ascertain family members' wishes and preferences for the dying patient's end-of-life care. Religious leaders (eg. priests) (25.1%, n = 108) and interpreters (4.9%, n = 21) contributed to ensuring family members could participate as desired, in accordance with cultural wishes and preferences.

CONCLUSIONS

Despite the culturally-diverse patient population, findings show that details about culturally sensitive end-of-life care are rarely documented. Comprehensive documentation is required of how clinicians assess patient and family member cultural wishes and preferences, in conjunction with how clinicians attempt to address these cultural needs.

Communicating with young children who have a parent dying of a life-limiting illness: a qualitative systematic review of the experiences and impact on healthcare, social and spiritual care professionals

Background

Healthcare professionals play a key role in interacting with children who have a parent with a life-limiting illness. While playing such a role can be challenging, not much is known about how such interactions impact these professionals and affect their ability to render support.

Methods

Four databases were searched with the intention to conduct a qualitative systematic review. Articles were selected based on pre-determined inclusion and exclusion criteria. Their quality was assessed using the tool "Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields”. Findings were analysed using thematic analysis techniques outlined by Thomas and Harden as well as Sandelowski and Barroso. Review was registered with the Review Registry database.

Results

Three themes emerged – healthcare professionals’ discomfort; their assumptions and actions; and potentiating workplace factors. The discomfort had several dimensions: fear of making a situation worse, concern of not being able to cope with emotionally charged situations, and internal conflict that arose when their values clashed with family dynamics.

Conclusion

Healthcare professionals’ sense of discomfort was very pronounced. This discomfort, together with their assumptions, could impact their ability to support children. The organisation played an important role, which was reflected in the work culture, workflow and ability to collaborate with other agencies involved in supporting children. The discomfort was mitigated by having more professional experience, workplace support systems and training on communicating with children. It was apparent that the individual professional did not work alone when supporting children but alongside others within an organisation. As such, issues raised in this review will benefit from multi-faceted solutions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01007-1.

[Experiencing brain death, physician view-a phenomenological approach]

AIM

The aim of the study was to examine how physicians experience caring for (potentially) brain-dead patients.

METHODS

Episodic interviews were conducted. Their evaluation was based on Benner's interpretative phenomenology.

RESULTS

Eleven physicians were interviewed. The following phenomena were extracted from the data: (1) encounter with the relatives, (2) making relatives understand brain death, (3) brain death is death, (4) experience of the nurses and (5) burdens.

CONCLUSION

The results show the complexity that is perceived by physicians when caring for a (potentially) brain-dead patient. The transition from saving the patient's life to preserving organs or switching off the equipment and informing the relatives requires a high level of expertise on the part of the physicians. The patients' symptoms provide the physicians with clear diagnostic procedures and any remaining ambiguities in the (treatment) process should be resolved.

End of life care pathways in the Emergency Department and their effects on patient and health service outcomes: An integrative review

INTRODUCTION

End of life (EOL) care in the Emergency Department (ED) requires focused, person-centred care to meet the needs of this vulnerable cohort of patients.

METHODS

An integrative review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was conducted. Studies were included if they were primary research relating to patients in the ED at the EOL, and/or evaluated EOL care pathways in the ED. Databases OVID Emcare, OVID Medline, and Scopus were searched from 1966-September 2021; followed by screening and appraisal. Articles were compared and data grouped into categories.

RESULTS

Eleven research articles were included generating three categories for EOL care in ED. 1) tools/criteria to identify patients who may require EOL care in ED; 2) processes for providing EOL care, and 3) implementation methods/frameworks to support the uptake of EOL care processes.

CONCLUSION

There were some commonalities in the criteria used to identify patients who may be at their EOL and the interventions implemented thereafter. There was no standardised process for screening for or treating EOL care needs in the ED. Further research is required to determine the impact that EOL care pathways have on patient and health service outcomes to inform strategies for future policy development.

End-of-life and hospice care for neurologic illness

Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.

Impact of Dying Neonates on Doctors' and Nurses' Personhood: A Systematic Scoping Review

CONTEXT

Caring for dying neonates is distressing for healthcare professionals (HCP)s. Yet, the extent of these effects is poorly understood, compromising support of HCPs. To better understand and support HCPs, a systematic scoping review (SSR) of prevailing data is proposed.

OBJECTIVES

In mapping prevailing data on the impact of caring for dying neonates on HCPs, an SSR proffers new insights on changes to their beliefs, values, coping, actions, relationships and self-concepts of personhood.

METHODS

Krishna's Systematic Evidenced Based Approach (SEBA) supports a robust, reproducible review whilst its constructivist approach and relativist lens effectively contends with diverse data sources, facilitating a holistic study.

RESULTS

A total of 9826 abstracts were reviewed and 69 articles were included. Thematic and content analysis were used simultanously. The four categories drawn from the Ring Theory of Personhood (RToP) complements the four themes identified: Emotional and Physical Difficulties, Coping Mechanisms, Conflict and Recommendations.

CONCLUSION

In highlighting significant longitudinal effects upon all aspects of their lives, this SSR in SEBA reveals a critical need for timely, appropriate and personalized support. We recommend adapting the RToP as an assessment tool to identify and evaluate the needs of these HCPs. It may also be used to structure a holistic support mechanism. Future studies are required to validate its use and appraise other aspects of support available for HCPs.

Effect of death and dying elective on student empathy and attitudes toward mortality

INTRODUCTION

Pharmacy graduates should be equipped for one inevitable aspect of health care, mortality, yet only 10% of United States pharmacy curricula courses cover end-of-life (EoL) with limited evidence of effectiveness. This study's objective was to evaluate the impact of an EoL elective on student pharmacists' empathy and attitudes toward mortality and caring for terminally ill persons.

METHODS

First- through third-year student pharmacists enrolled in an EoL elective. Students completed pre- and post-course surveys on self-perceptions of empathy and mortality. Surveys included the following: Kiersma-Chen Empathy Scale (KCES), which assesses empathy of pharmacy and nursing students; revised Collett-Lester Fear of Death and Dying Scale (CL-FODS), which measures fear related to death; and Frommelt Attitudes Toward Care of the Dying Scale Form B (FATCOD-B), which measures health care professionals' attitudes toward EoL care. Anonymous identifiers were used to link pre- and post-course surveys and were collected with an online survey software. Data were analyzed using two-sided paired t-tests.

RESULTS

Twenty-seven student pharmacists completed the elective. The change in overall mean scores for KCES, CL-FODS, and FATCOD-B correlated with increased empathy, reduced fear of death, and increased positive attitudes toward caring for terminal patients (KCES pre-course = 86.15 vs. post-course = 90.37; CL-FODS pre-course = 93.70 vs. post-course = 75.15; FATCOD-B pre-course = 115.89 vs. post-course = 124.04).

CONCLUSIONS

After the EoL elective, student empathy and attitudes toward mortality and caring for terminally ill persons improved. Implementing EoL concepts in pharmacy curricula should be explored to better prepare graduates in patient care.

Literary mentorship on the art of living, aging and dying

This article offers a fresh examination of Mitch Albom's bestseller Tuesdays with Morrie (1997) from a perspective of literary age studies, with a special focus on the concept of later-life mentorship. The classic mentor figure, commonly seen as the archetype of a wise old teacher, is revived through the healing power of an end-of-life narrative. The mentorial relationship between a young man and an old man shows that the personal growth is as an ongoing and ageless process of becoming that can lead to wisdom and a better understanding of aging and living-with-dying. It also reveals that later-life narratives of mentorship are an integral part of the transmission of knowledge and humanistic values to establish solid relationships between generations. Life lessons with Morrie, collected in the form of a memoir, provide readers with important tools to learn to accept life in all its dimensions, and show how literary narratives of growing older can help deconstruct negative western notions of old age and lead to more meaningful lives in all life stages.

A novel care guide for personalised palliative care - a national initiative for improved quality of care

Background

Even when palliative care is an integrated part of the healthcare system, the quality is still substandard for many patients and often initiated too late. There is a lack of structured guidelines for identifying and caring for patients; in particular for those with early palliative care needs. A care guide can act as a compass for best practice and support the care of patients throughout their palliative trajectory. Such a guide should both meet the needs of health care professionals and patients and families, facilitating discussion around end-of-life decision-making and enabling them to plan for the remaining time in life. The aim of this article is to describe the development and pilot testing of a novel Swedish palliative care guide.

Methods

The Swedish Palliative Care Guide (S-PCG) was developed according to the Medical Research Council framework and based on national and international guidelines for good palliative care. An interdisciplinary national advisory committee of over 90 health care professionals together with patient, family and public representatives were engaged in the process. The feasibility was tested in three pilot studies in different care settings.

Results

After extensive multi-unit and interprofessional testing and evaluation, the S-PCG contains three parts that can be used independently to identify, assess, address, follow up, and document the individual symptoms and care-needs throughout the whole palliative care trajectory. The S-PCG can provide a comprehensive overview and shared understanding of the patients’ needs and possibilities for ensuring optimal quality of life, the family included.

Conclusions

Based on broad professional cooperation, patients and family participation and clinical testing, the S-PCG provides unique interprofessional guidance for assessment and holistic care of patients with palliative care needs, promotes support to the family, and when properly used supports high-quality personalised palliative care throughout the palliative trajectory. Future steps for the S-PCG, entails scientific evaluation of the clinical impact and effect of S-PCG in different care settings – including implementation, patient and family outcomes, and experiences of patient, family and personnel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00874-4.

"Saying goodbye all alone with no close support was difficult"- Dying during the COVID-19 pandemic: an online survey among bereaved relatives about end-of-life care for patients with or without SARS-CoV2 infection

BACKGROUND

During the SARS-CoV2 pandemic, protection measures, as well as visiting restrictions, had a severe impact on seriously ill and dying patients and their relatives. The study aims to describe the experiences of bereaved relatives of patients who died during the SARS-CoV2 pandemic, regardless of whether patients were infected with SARS-CoV2 or not. As part of this, experiences related to patients' end-of-life care, saying goodbye, visiting restrictions and communication with the healthcare team were assessed.

METHODS

An open observational post-bereavement online survey with free text options was conducted with 81 bereaved relatives from people who died during the pandemic in Germany, with and without SARS-CoV2 diagnosis.

RESULTS

67/81 of the bereaved relatives were female, with a mean age of 57.2 years. 50/81 decedents were women, with a mean age of 82.4 years. The main underlying diseases causing death were cardiovascular diseases or cancer. Only 7/81 of the patients were infected with SARS-CoV2. 58/81 of the relatives felt burdened by the visiting restrictions and 60/81 suffered from pandemic-related stress. 10 of the patients died alone due to visiting restrictions. The burden for relatives in the hospital setting was higher compared to relatives of patients who died at home. 45/81 and 44/81 relatives respectively reported that physicians and nurses had time to discuss the patient's condition. Nevertheless, relatives reported a lack of proactive communication from the healthcare professionals.

CONCLUSIONS

Visits of relatives play a major role in the care of the dying and have an impact on the bereavement of relatives. Visits must be facilitated, allowing physical contact. Additionally, virtual contact with the patients and open, empathetic communication on the part of healthcare professionals is needed.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00023552).

Nursing students perceptions of death and dying: A descriptive quantitative study

BACKGROUND

Nurses are frequently present during the dying process as a support for the dying person and the family. Experiencing death in this capacity can cause emotional and psychological stress to the nursing staff as they work to help others. Nursing students as the upcoming generation of nurses, need the knowledge and self-awareness to support others through these often traumatic events. Many students may not have experience with death or dying and when combined with lack of knowledge will be a great barrier once students graduate.

OBJECTIVES

The purpose of this study is to determine how sophomore, junior, and senior undergraduate nursing students enrolled in one University setting perceive the concept of death and dying.

DESIGN

A descriptive quantitative study was designed to explore the various perceptions that sophomore, junior, and senior nursing students have about death and dying.

RESULTS

The Frommelt Attitudes Toward Care of the Dying scale showed students have a positive attitude toward caring for dying patients. The Death Attitudes Profile-Revised scale indicated the presence of all profiles, though most students identified with Neutral Acceptance profile.

CONCLUSIONS

Nursing students often fear caring for clients with death or dying. Additional targeted education along with end of life care simulations can improve students improve their attitudes and beliefs to better care for patients.

A national Position Statement on adult end-of-life care in critical care

Patient death in critical care is not uncommon. Rather, the provision of end-of-life care is a core feature of critical care nursing, yet not all nurses feel adequately prepared for their role in the provision of end-of-life care. For this reason, the Australian College of Critical Care Nurses (ACCCN) supported the development of a Position Statement to provide nurses with clear practice recommendations to guide the provision of end-of-life care, which reflect the most relevant evidence and information associated with end-of-life care for adult patients in Australian critical care settings. A systematic literature search was conducted between June and July, 2020 in CINAHL Complete, Medline, and EMBASE databases to locate research evidence related to key elements of end-of-life care in critical care. Preference was given to the most recent Australian or Australasian research evidence, where available. Once the practice recommendations were drafted in accordance with the research evidence, a clinical expert review panel was established. The panel comprised clinically active ACCCN members with at least 12 months of clinical experience. The clinical expert review panel participated in an eDelphi process to provide face validity for practice recommendations and a subsequent online meeting to suggest additional refinements and ensure the final practice recommendations were meaningful and practical for critical care nursing practice in Australia. ACCCN Board members also provided independent review of the Position Statement. This Position Statement is intended to provide practical guidance to critical care nurses in the provision of adult end-of-life care in Australian critical care settings.

Divergent patterns of confrontation with death using the Anticipated Farewell to Existence Questionnaire (AFEQT): a cross-sectional comparative study of four samples with increasing proximity to death

BACKGROUND

Based on the concept of "Daseinsverabschiedung", an anthropological theory of "Anticipated Farewell to Existence" (AFE) was suggested on the basis of six grounding dimensions: selfhood, interpersonality, temporality, corporeality, worldliness, and transcendence, which are activated in a genuine manner facing death. The purpose of the study is to quantitatively compare the extent of confrontation with death between dying people in palliative care and those in other stages of life by means of the Anticipated Farewell to Existence Questionnaire" (AFEQT), based on these dimensions.

METHODS

The sample (N = 485) consists of dying individuals in palliative wards and hospices (n = 121); old people living in nursing homes not suffering from a mortal disease (n = 62); young adults (n = 152), and middle-aged adults (n = 150). The design is cross-sectional and analytical. The relevance of anticipated farewell to existence was measured by means of the AFEQT. The internal consistency of the AFEQT was assessed using Cronbach's alpha and convergent validity by means of dimensions of the Life Attitude Profile-Revised (LAP-R). Differences between groups and associations with control variables were estimated by means of multiple regression models, including propensity scores.

RESULTS

Cronbach's alpha for AFEQT was > 0.80 for the whole test and all subsamples, but < 0.70 for most dimensions in dying people. Correlations between each dimension and corresponding two factors was almost overall r > 0.80, p < 0.001. Good convergent validity between dimensions of AFEQT and of Life Attitude Profile-Revised in young and middle-aged participants showed correlations for superordinate indices between -0.23 and 0.72, and an overall p < 0.001. Dying people scored significantly higher for all dimensions, especially "altruistic preoccupation" and "reconciliation with existence" than people in other life stages (p < 0.01- < 0.001). Personality traits of "openness" and "agreeableness" are positively associated with higher scoring of AFEQT dimensions. About 77% of dying participants reported a personal benefit through the interview questions.

CONCLUSIONS

With proximity to death, the anthropological dimensions proposed scored significant higher than in other stages of life, reflecting a stronger awareness, confrontation and reconciliation with the end of their own life. These dimensions, especially preoccupation for related persons and coexistence of acceptance and struggle with death have to be taken into account in a sensitive way by supporting dialogues with dying people and their relatives.

TRIAL REGISTRATION

Observational cross-sectional study.

Constitution of "The Already Dying": The Emergence of Voluntary Assisted Dying in Victoria

In June 2019 Victoria became the first state in Australia to permit "voluntary assisted dying" (VAD), with its governance detailed in the Voluntary Assisted Dying Act 2017 (Vic) ("VAD Act"). While taking lead from the regulation of medically assisted death practices in other parts of the world, Victoria's legislation nevertheless remains distinct. The law in Victoria only makes VAD available to persons determined to be "already dying": it is expressly limited to those medically prognosed to die "within weeks or months." In this article, we discuss the emergence of the Victorian legislation across key formative documents. We show how, in devising VAD exclusively for those "already at the end of their lives", the Victorian state mobilizes the medico-legal category of the already dying. We argue that this category functions to negotiate a path between what are seen as the unacceptable alternatives of violent suicide on the one hand, and an unlimited right to die on the other. Further, we argue that the category of the already dying operates to make medical practitioners the gatekeepers of this new life-ending choice and effectively limits the realization of autonomy at the end of life.

A scoping research literature review to map the evidence on grief triggers

Grief is understandably severe in the first days, if not weeks or months, following the death of a beloved person. Unless the mourner develops complicated grief, which is prolonged severe and impactful grief, the initial acute grief lessens in severity over time, although waves of significant grief will still occur with grief triggers. A scoping research literature review was undertaken in early 2021 to determine how often grief triggers occur, what the most common grief triggers are, the impact of triggered grief, and what can be done (by those not diagnosed with complicated grief) to manage grief triggers and mitigate the effect of them. Nine academic library databases were searched for English-language research reports using the keywords "grief trigger(s)" and "research": CINAHL, Directory of Open Access (online) Journals, Humanities Index, JSTOR, Medline (Ovid), Periodicals Index Online, PsychArticles, Scopus, and Web of Science. Six research papers relevant for review were published in the last two decades, with some evidence gained on how often grief triggers occur, what constitutes a grief trigger, and the impact of grief triggers. Major gaps in evidence were revealed, despite grief triggers being identified as a major consideration for grief in general and for grief recovery specifically.

Harming patients by provision of intensive care treatment: is it right to provide time-limited trials of intensive care to patients with a low chance of survival?

Time-limited trials of intensive care have arisen in response to the increasing demand for intensive care treatment for patients with a low chance of surviving their critical illness, and the clinical uncertainty inherent in intensive care decision-making. Intensive care treatment is reported by most patients to be a significantly unpleasant experience. Therefore, patients who do not survive intensive care treatment are exposed to a negative dying experience. Time-limited trials of intensive care treatment in patients with a low chance of surviving have both a small chance of benefiting this patient group and a high chance of harming them by depriving them of a good death. A 'rule of rescue' for the critically unwell does not justify time-limiting a trial of intensive care treatment and overlooks the experiential costs that intensive care patients face. Offering time-limited trials of intensive care to all patients, regardless of their chance of survival, overlooks the responsibility of resource-limited intensive care clinicians for suffering caused by their actions. A patient-specific risk-benefit analysis is vital when deciding whether to offer intensive care treatment, to ensure that time-limited trials of intensive care are not undertaken for patients who have a much higher chance of being harmed, rather than benefited by the treatment. The virtue ethics concept of human flourishing has the potential to offer additional ethical guidance to resource-limited clinicians facing these complex decisions, involving the balancing of a quantifiable survival benefit against the qualitative suffering that intensive care treatment may cause.

The Role of Religion in Physician Outlook on Death, Dying, and End of Life Care

One of the many roles a physician provides to their patients is compassion and comfort, which includes tending to any psychological, spiritual, and religious needs the patient has. The goal of this pilot study was to explore whether religious or spiritual values of physicians at an urban academic hospital affect how physicians care for and communicate with their patients, especially when dealing with death, dying, and end-of-life matters. After surveying 111 inpatient physicians at an academic hospital, we found that 92% of physicians are extremely or somewhat comfortable having end-of-life discussions. We also found that physician religiosity and spirituality are not necessarily required for discussing death and dying and that the religious and spiritual values of the physician do not correlate with their ability to have end-of-life conversations with the patient. We found no difference between years in practice and comfort discussing religion and spirituality, though we did find that, of the physicians who believe they are comfortable talking to patients about religion or belief systems, most of them had more than five end-of-life patients in the past 12 months. Lastly, referrals to Palliative Care or pastoral services were not impacted by the physician's religious or spiritual beliefs. Future studies can explore how religious beliefs may more subtly influence physicians' interactions with patients, patient satisfaction, and physician well-being and resilience.

Ethical Pain and Terminal Chaperonage

Terminal chaperonage embedded in palliative care deeply resonates with human needs and has undergone significant advances in the past decades. At the same time, it is in jeopardy due to austerity measures in healthcare. Its comprehensive translation in philanthropic end-of-life practice necessitates reflection on underlying ethical issues. This chapter addresses ethical aspects arising in pain and terminal chaperonage and deduces important ethical imperatives in the wake of the palliative mandate. The imperatives affect the deployment of resources necessary for a humane pain and terminal chaperonage, one that is to be comprehensive and flexible in design and implementation at the same time. Furthermore, they are concerned with critical implications for dying clients emerging from the idiosyncratic properties of opioids with respect to their potential to induce mental status alterations. Given that living and dying are profoundly mental by nature, the human mind plays a fundamental role in the command of both. Based on this, this chapter also outlines the essentials of terminal thought plasticity and affect catharsis en route to a mindful, decent death. It identifies and advocates eight most fundamental affective, respectively cognitive fields of the human mind, the "Ensemble of the essential eight iridescent fields of relinquishment", whose adaptable, culturally sensitive facilitation in mental management prior to death may have to be considered the core ethical imperative in terminal chaperonage - in true congruence with philanthropic end-of-life care.

Placing death and dying: Making place at the end of life

Over the last decade, policies in both the UK and many other countries have promoted the opportunity for patients at the end of life to be able to choose where to die. Central to this is the expectation that in most instances people would prefer to die at home, where they are more likely to feel most comfortable and less medicalised. In so doing, recording the preferred place of death and reducing the number of hospital deaths have become common measures of the overall quality of end of life care. We argue that as a consequence, what constitutes a desired or appropriate place is routinely defined in a very simple and static 'geographical' way, that is linked to conceptualising death as an unambiguous and discrete event that happens at a precise moment in time in a specific location. In contrast, we draw on 18 months of ethnographic fieldwork with two inner-London palliative care teams to describe the continual work staff do to make places suitable and appropriate for the processes of dying, rather than for a singular event. In this way, instead of 'place of death' merely defined in geographic terms, the palliative care staff attend to the much more dynamic relation between a patient and their location as they approach the end of their life. Central to this is an emphasis on dying as an open-ended process, and correspondingly place as a social space that reflects, and interacts with, living persons. We propose the term 'placing work' to capture these ongoing efforts as a patient's surroundings are continually altered and adjusted over time, and as a way to acknowledge this as a significant feature of the care given.

From the shadows of death into the light of acceptance: A lived experience of patients with HIV-AIDS

HIV/AIDS is one of the feared diseases worldwide. It is a disease thoroughly studied yet still incurable in this modern era. Having acquired it is like being faced with the possibility of spending life in limbo-marked by the disease, excluded from the norms of society and an outcast to many. The study has aimed to capture how patients with HIV/AIDS struggled with living with the disease, the obstacle they had to overcome and how they were able to deal with the problems that they encountered after being diagnosed with such disease. A descriptive phenomenology utilizing a semi-structured face-to-face interview was used. Four key informants (KI) from Metro Manila shared their lived experiences unreservedly. Through Colaizzi's data analysis two major themes and five subthemes reflected the lived experiences of dying persons living with HIV/AIDS: (1) Scourging of the Pessimistic Spirits (a) fear is a dark room where negatives are developed, (b) a spirit crying for succor. (2) Rise of the Optimistic Spirit (a) burning bush in the darkness, (b) transformation in the midst of the battle for life (c) acceptance as transcending condition. In learning their HIV/AIDS diagnosis, the KI had to go through a series of steps in their lives to accommodate this major trial into their identity. They had to experience the psychological distress and the physical limitations caused by the disease before discovering that they do not have to live in fear and isolation. They were able to emerge from the darkness of negativity into the light of acceptance and hope and have used their experiences as a way to teach and support others who are in the same predicament as they were before. They have also learned to accept their imminent death as part of their life.

Attitudes and educational needs of emergency doctors providing palliative and end-of-life care in Hong Kong: a cross-sectional analysis based on a self-report study

Background

Due to the ageing population in Hong Kong, the importance and need of palliative care and end-of-life (EOL) care are coming under the spotlight. The objectives of this study were to evaluate the attitudes of emergency doctors in providing palliative and EOL care in Hong Kong, and to investigate the educational needs of emergency doctors in these areas.

Methods

A questionnaire was used to study the attitudes of ED doctors of six different hospitals in Hong Kong. The questionnaire recorded the attitudes of the doctors towards the role of palliative and EOL care in EDs, the specific obstacles faced, their comfort level and further educational needs in providing such care. The attitudes of emergency doctors of EDs with EOL care services were compared with those of EDs without such services.

Results

In total, 145 emergency doctors completed the questionnaire, of which 60 respondents were from EDs with EOL care services. A significant number of participants recognized that the management of the dying process was essential in ED. Providing palliative and EOL care is also accepted as an important competence and responsibility, but the role and priority of palliative and EOL care in ED are uncertain. Lack of time and access to palliative care specialists/ teams were the major barriers. Doctors from EDs with EOL care services are more comfortable in providing such care and discuss it with patients and their relatives. Further educational needs were identified, including the management of physical complaints, communication skills, and EOL care ethics.

Conclusions

The study identified obstacles in promoting palliative and EOL care in the EDs Hong Kong. With the combination of elements of routine ED practice and a basic palliative medicine skill set, it would promote the development of palliative and EOL care in Emergency Medicine in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00742-1.

Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study

BACKGROUND

Scaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU).

METHODS

In a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement.

RESULTS

Both qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization.

CONCLUSIONS

The 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

Older persons' thoughts about death and dying and their experiences of care in end-of-life: a qualitative study

Background

Few studies have focused on how older persons living in nursing homes perceive their last period of life. Furthermore, previous research on older persons’ perceptions of death and dying is limited. Hence, there is an urgent need to explore their experiences during their final period in life.

Aim

To explore thoughts about death and dying and experiences of care in end-of-life among older persons living in nursing homes.

Methods

This study employed a qualitative approach including individual interviews with 36 older persons living in Swedish nursing homes. Questions related to quality of life; physical health; thoughts about death, dying, and the future; and experiences related to the living condition and environment were asked. The interview transcripts were analysed through content analysis. The study was approved by the Regional Ethics Review Board (reference number: 2015/4).

Results

The analysis resulted in the identification of three main thematic categories: The unavoidable and unknown end of life, Thoughts on control and Living your last period of life at a nursing home. The older persons did not fear death itself but had some worries about dying. Spending the last stage of life at a nursing home contributed to different thoughts and feelings among the older persons. With a few exceptions, older persons characterized life at the nursing home as boring and felt they were surrounded by people who did not belong there.

Conclusions

This study indicates a need for older persons to talk about death, dying and end-life issues. Furthermore, this study highlighted that the co-residence of cognitively healthy persons and persons with dementia in the same ward adversely affected cognitively healthy persons. This situation resulted in there being not enough time to both handle the care needs of persons with dementia and have the conversations that cognitively healthy persons desired, such as conversations about thoughts about existence, that could have improved their quality of life.

Trial registration

NCT02708498 Date of registration 16 February 2016.

Unsettling Place(s) at the end of life

Critical considerations of space and place at the end of life have been limited in the social science literature. To address this gap, we draw on empirical data from two interrelated but separate qualitative Australian data sets to critically examine dying in relation to considerations of space, place and affect. These studies share the primary aim to better understand and articulate end-of-life experiences, with one using video reflexive ethnography and the other semi-structured interviews with patients. Challenging the broader valorisation of particular places of dying and death (e.g. home, hospice, hospital), we critically explore the meanings and affects of space and place and how they are rooted in normative expectations. Drawing on participant accounts we interrogate simplistic concepts of home versus hospice, or hospital versus community, developing a critical social science of the intersections of space and place at the end of life.

One last round of chemo? Insights from conversations between oncologists and lung cancer patients about prognosis and treatment decisions

One more chemo or one too many? The increasing use of expensive cancer treatments close to the patient's death is often explained by oncologists' failure to communicate to patients how close to dying they are, implying that patients are often both ill-prepared and over-treated when they die. This article aims at interrogating the politically charged task of prognosticating. Drawing on an ethnographic study of conversations between oncologists and patients with metastatic lung cancer in a Danish oncology clinic, I show that oncologists utilize, rather than avoid, prognostication in their negotiations with patients about treatment withdrawal. The study informs the emerging sociology of prognosis in three ways: First, prognostication is not only about foreseeing and foretelling, but also about shaping the patient's process of dying. Second, oncologists prognosticate differently depending on the level of certainty about the patient's trajectory. To unfold these differences, the article provides a terminology that distinguishes between four 'modes of prognostication', namely hinting, informing, calibrating and organizing. Third, prognosticating can unfold over time through multiple consultations, emphasizing the relevance of adopting methodologies enabling the study of prognosticating over time.

To die well: the phenomenology of suffering and end of life ethics

The paper presents an account of suffering as a multi-level phenomenon based on concepts such as mood, being-in-the-world and core life value. This phenomenological account will better allow us to evaluate the hardships associated with dying and thereby assist health care professionals in helping persons to die in the best possible manner. Suffering consists not only in physical pain but in being unable to do basic things that are considered to bestow meaning on one's life. The suffering can also be related to no longer being able to be the person one wants to be in the eyes of others, to losing one's dignity and identity. These three types of suffering become articulated by a narrative that holds together and bestows meaning on the whole life and identity of the dying person. In the encounter with the patient, the health-care professional attempts to understand the suffering-experience of the patient in an empathic and dialogic manner, in addition to exploring what has gone wrong in the patient's body. Matters of physician assisted suicide and/or euthanasia-if it should be legalized and if so under which conditions-need to be addressed by understanding the different levels of human suffering and its positive counterpart, human flourishing, rather than stressing the respect for patient autonomy and no-harm principles, only. In this phenomenological analysis the notions of vulnerability and togetherness, ultimately connecting to the political-philosophical issues of how we live together and take care of each other in a community, need to be scrutinized.

Nurses' early and ongoing encounters with the dying and the dead: a scoping review of the international literature

BACKGROUND

End-of-life care is high on policy and political agendas in the UK and internationally. Nurses are at the forefront of this, caring for dying patients, 'managing' the dead body, and dealing with the corporeal, emotional and relational dimensions of death. Little is known about nurses' prior or early professional experiences of and reactions to death, dying and the corpse and how these might influence practice.

AIMS

To appraise the international literature on nurses' early experiences of death, dying and the dead body, to better understand how these might influence subsequent practice, and how this might inform our teaching of death, dying and last offices.

METHODS

A scoping review was undertaken of peer-reviewed publications between, 2000 and 2019, which included nurses working in hospital, care homes and the community. Medline, PubMed, PsychINFO and CINAHL databases were searched and 23 papers meeting the inclusion criteria were read. Arksey and O'Malley's (2005) five-stage approach was adopted to scope the relevant international literature, using where relevant the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Selected papers were independently reviewed and subjected to thematic analysis, leading to the generation of five overarching themes.

RESULTS

The five themes were: different philosophies of care; relationships; knowledge; impact of death; and giving care. The studies came from diverse geographical locations across different settings and were primarily qualitative in design.

CONCLUSIONS

Students and registered nurses are impacted both positively and negatively by their early encounters with death and dying. Good communication with patients, families and between professionals, understanding of what constitutes a 'good' death, and high-quality mentorship and support were of particular importance.

Emotionally reflexive labour in end-of-life communication

Within palliative care, clear and open communication about death is encouraged. Euphemisms are discouraged as threats to promoting clear understanding of the prognosis; to opening communication about what a good death means to individual patients and families; and to fostering collaborative planning aimed at achieving this 'good death'. Principles of patient-centred and culturally competent care, however, which reflect trends of individualisation, plurality and multiculturalism that are characteristic of late modernity, encourage respect for and support of patients' and families' preferences. These may include wishes to avoid open communication, preferences for euphemisms, and definitions of a 'good death' that vary from the practitioner's, and within families. The aim of this study was to examine how physicians navigate these competing priorities. Analysis is based on interviews with 23 doctors, ranging in experience from medical students through to senior palliative care specialists, and eight recorded observations of palliative care multidisciplinary team meetings with 52 clinicians collected in 2017 at two hospitals in one Australian metropolitan area. Findings show that synonyms familiar to clinicians are often used to communicate prognoses in multidisciplinary meetings. In communication with patients and families, doctors rely on emotional and cultural cues to decipher the preferred terminology and response. Drawing on a late modern re-imagination of emotion management, we conceptualise the work performed in this context as emotionally reflexive labour. These findings suggest that blanket protocols for direct communication overlook the complexity of end-of-life communication in an era where a 'good death' is understood to be culturally relative.

Heideggerian hermeneutic phenomenology as method: modelling analysis through a meta-synthesis of articles on Being-towards-death

While the richness of Heideggerian philosophy is attractive as a healthcare research framework, its density means authors rarely utilise its fullest possibilities as an hermeneutic analytic structure. This article aims to clarify Heideggerian hermeneutic analysis by taking one discrete element of Heideggerian philosophy (Being-towards-death), and using it's clearly defined structure to conduct a meta-synthesis of Heideggerian phenomenological studies on the experience of living with a potentially life-limiting illness. The findings richly illustrate Heidegger's philosophy that there is either an inauthentic positioning towards death, or an authentic positioning towards death with a proposition that (1) death is certain; (2) death is indefinite; (3) death is non-relational; and (4) death is not-to-be-outstripped. None of the 29 included studies on the experience of a confrontation with death fully utilised this framework, despite claiming a grounding in Heideggerian thought. This demonstrates the value in modelling how Heideggerian existential structures can be used proactively as analytical 'hooks' for data in research claiming a basis in this philosophy and/or method. By modelling the potential application of an important Heideggerian philosophical construct to published qualitative data, this meta-synthesis has revealed new domains and more nuanced understandings of the temporal structure of Being-towards-death. Such an approach helps to more fully unveil the existential concerns of people at the core of interpretative phenomenological enquiry and may provide a blueprint to map either primary or synthesised data to other key ontological existentials.

Pros and Cons of Physician Aid in Dying

The question of a physician's involvement in aid in dying (or "assisted suicide") is being debated across the country. This article adopts no one position because its authors hold contrasting views. It aims instead to articulate the strongest arguments in favor of aid in dying and the strongest arguments opposed. It also addresses relevant terminology and reviews the history of its legalization in the United States.

Identifying neuronal correlates of dying and resuscitation in a model of reversible brain anoxia

We developed a new rodent model of reversible brain anoxia and performed continuous electrocorticographic (ECoG) and intracellular recordings of neocortical neurons to identify in real-time the cellular and network dynamics that successively emerge throughout the dying-to-recovery process. Along with a global decrease in ECoG amplitude, deprivation of oxygen supply resulted in an early surge of beta-gamma activities, accompanied by rhythmic membrane depolarizations and regular firing in pyramidal neurons. ECoG and intracellular signals were then dominated by low-frequency activities which progressively declined towards isoelectric levels. Cortical neurons during the isoelectric state underwent a massive membrane potential depolarizing shift, captured in the ECoG as a large amplitude triphasic wave known as the "wave-of-death" (WoD). This neuronal anoxic depolarization, associated with a block of action potentials and a loss of cell integrative properties, could however be reversed if brain re-oxygenation was rapidly restored (within 2-3.5 min). The subsequent slow repolarization of neocortical neurons resulted in a second identifiable ECoG wave we termed "wave-of-resuscitation" since it inaugurated the progressive regaining of pre-anoxic synaptic and firing activities. These results demonstrate that the WoD is not a biomarker of an irremediable death and unveil the cellular correlates of a novel ECoG wave that may be predictive of a successful recovery. The identification of real-time biomarkers of onset and termination of cell anoxic insult could benefit research on interventional strategies to optimize resuscitation procedures.

The emotional labour of quality improvement work in end of life care: a qualitative study of Patient and Family Centred Care (PFCC) in England

Background

There is a growing emphasis on understanding patient experience in order to inform efforts to support improvement. This paper reports findings from an implementation study of an evidence-based intervention called Patient and Family Centred Care (PFCC) designed to tap into patient experiences as a basis for improvement. In this study the PFCC intervention was spread to a new service area (end of life care) and delivered at scale in England. The findings presented here focus specifically on one key aspect of the intervention: staff shadowing of patients, and the experiences of staff carrying out shadowing for the purposes of service improvements.

Methods

The study methods were ethnographic observations of key events, semi-structured interviews with members of participating teams and the programme implementation support team and managers, and a review of the documents used in the set up and running of the programme.

Results

One of the key strengths of the PFCC approach is to encourage staff through shadowing to engage with patient experience of services. Many staff described the process of shadowing as a transformative experience that alerted them to immediate areas where their services could be improved. However, engaging with patient experience of end of life care services also had unintended consequences for some staff in the form of emotional labour. Furthermore, we observed difficulties encountered by staff that are not accounted for in the existing PFCC literature relating to how care service structures may unevenly distribute the amount of ‘emotional labour’ that staff members need to invest in implementing the programme.

Conclusions

Connecting with patient experience is a crucial aspect of a number of quality improvement interventions that aim to help staff to engage with the lived experience of their services and reconnect their motivations for working in the health care system. However, there may be unintended consequences for health care service staff, particularly in sensitive areas of service delivery such as end of life care. The ‘emotional labour’ for staff of engaging in quality improvement work informed by patient experience should be considered in planning and supporting patient experience led quality improvement.

Palliative Care for Dementia: 2020 Update

Dementia management is complicated by neuropsychiatric symptoms such that the longitudinal care of a psychiatrist or other mental health provider is often an essential part of patient care and a major source of family support. Given the importance of end-of-life continuity of care, the involvement of psychiatry in palliative and hospice services affords an important opportunity for growth. Common challenges involve sharing prognostic information with patients and families to aid in advance planning, and management of persistent pain and nutritional issues. Future research will yield important new insights and guidelines for care.

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.