"To Speak of Death Is to Invite It": Provider Perceptions of Palliative Care for Cardiovascular Patients in Western Kenya

Web-based psychoeducational intervention for bereaved parents

BACKGROUND

There is a lack of theoretically sound, scientifically-tested interventions for bereaved parents.

AIMS

To describe the acceptability and feasibility testing of an online grief-support-resource platform for bereaved parents.

METHODS

Participants included 20 parents of children who had died from a disease. The study involved a quasi-experimental treatment-only two-site design.

FINDINGS

The study was not able to recruit the intended number of participants. The website designed to support parents during grieving was found to be helpful by participants (43% enrolment rate), though not feasible. Lessons learned from this trial include: to use a well-defined eligibility criteria; follow a model for behavioural intervention development in a stepwise fashion, not exceed the individual stage's purpose; cautiously approach bereaved parents less than 6 months after a child's death; and comprehensive parent orientation to the grief-support-resource platform.

CONCLUSION

Transparent sharing of lessons learned provide opportunities for investigators who are planning studies to learn from this team's experience.

Application of Terror Management Theory to End-Of-Life Care Decision-Making: A Narrative Literature Review

Patients with serious illnesses often do not engage in discussions about end-of-life care decision-making, or do so reluctantly. These discussions can be useful in facilitating advance care planning and connecting patients to services such as palliative care that improve quality of life. Terror Management Theory, a social psychology theory stating that humans are motivated to resolve the discomfort surrounding their inevitable death, has been discussed in the psychology literature as an underlying basis of human decision-making and behavior. This paper explores how Terror Management Theory could be extended to seriously ill populations and applied to their healthcare decision-making processes and quality of care received.

The quality of death and dying of patients with advanced cancer in hospice care in Uganda and Kenya

OBJECTIVES

Minimal information is available about the quality of dying and death in Uganda and Kenya, which are African leaders in palliative care. We investigated the quality of dying and death in patients with advanced cancer who had received hospice care in Uganda or Kenya.

METHODS

Observational study with bereaved caregivers of decedents (Uganda: n = 202; Kenya: n = 127) with advanced cancer who had received care from participating hospices in Uganda or Kenya. Participants completed the Quality of Dying and Death questionnaire and a measure of family satisfaction with cancer care (FAMCARE).

RESULTS

Quality of Dying and Death Preparation and Connectedness subscales were most frequently rated as good to almost perfect for patients in both countries (45.5% to 81.9%), while Symptom Control and Transcendence subscales were most frequently rated as intermediate (42.6% to 60.4%). However, 35.4% to 67.7% of caregivers rated overall quality of dying and overall quality of death as terrible to poor. Ugandan caregivers reported lower Preparation, Connectedness, and Transcendence (p < .001). Controlling for covariates, overall quality of dying was associated with better Symptom Control in both countries (p < .001) and Transcendence in Uganda (p = .010); overall quality of death, with greater Transcendence in Uganda (p = .004); and family satisfaction with care, with better Preparation in Uganda (p = .004).

SIGNIFICANCE OF RESULTS

Findings indicate strengths in spiritual and social domains of the quality of dying and death in patients who received hospice care in Uganda and Kenya, but better symptom control is needed to improve this outcome in these countries.

Heart Failure Care Facilitators and Barriers in Rural Haiti: A Qualitative Study

Background: Heart failure (HF) is a leading cause of hospitalizations in Haiti. However, few patients return for outpatient care. The factors contributing to chronic HF care access are poorly understood. Objective: The purpose of this study is to investigate the facilitators and barriers to accessing care for chronic HF from the patients' perspectives. Methods: We conducted a qualitative descriptive study of 13 patients with HF participating in three group interviews and one individual interview. We recruited patients after discharge from a nongovernmental organization-supported academic hospital in rural Haiti. We employed thematic analysis using emergent coding and categorized themes using the socioecological model. Findings: Facilitators of chronic care included participants' knowledge about the importance of treatment for HF and engagement with health systems to manage symptoms. Social support networks helped participants access clinics. Participants reported low cost of care at this subsidized hospital, good medication accessibility, and trust in the healthcare system. Participants expressedstrong spiritual beliefs, with the view that the healthcare system is an extension of God's influence. Barriers to chronic care included misconceptions about the importance of adherence to medications when symptoms improve and remembering follow-up appointments. Unexpectedly, participants believed they should take their HF medications with food and that food insecurity resulted in missed doses. Lack of social support networks limited clinic access. The nonhealthcare costs associated with clinic visits were prohibitive for many participants. Participants expressed low satisfaction regarding the clinic experience. A barrier to healthcare was the belief that heart disease caused by mystical and supernatural spirits is incurable. Conclusions: We identified several facilitators and barriers to chronic HF care with meaningful implications for HF management in rural Haiti. Future interventions to improve chronic HF care should emphasize addressing misconceptions about HF management and fostering patient support systems for visit and medication adherence. Leveraging local spiritual beliefs may also promote care engagement.

Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Resource Settings-A Two-Arm Interventional Feasibility Study

INTRODUCTION

Pediatric mortality remains unacceptably high in many low-resource settings, with inpatient deaths often associated with delayed recognition of clinical deterioration. The Family-Assisted Severe Febrile Illness ThERapy (FASTER) tool has been developed for caregivers to assist in monitoring their hospitalized children and alert clinicians. This study evaluates feasibility of implementation by caregivers and clinicians.

METHODS

Randomized controlled feasibility study at Kenyatta National Hospital, Kenya. Children hospitalized with acute febrile illness with caregivers at the bedside for 24 h were enrolled. Caregivers were trained using the FASTER tool. The primary outcome was the frequency of clinician reassessments between intervention (FASTER) and standard care arms. Poisson regression with random intercept for grouping by patient was used, adjusting for admission pediatric early warning score, age, gender. Secondary outcomes included survey assessments of clinician and caregiver experiences with FASTER.

RESULTS

One hundred and fifty patient/caregiver pairs were enrolled, 139 included in the analysis, 74 in the intervention, 65 in the control arm. Patients' median age was 0.9 (range 0.2-10) and 1.1 years (range 0.2-12) in intervention vs. control arms. The most common diagnoses were pneumonia (80[58%]), meningitis (58[38%]) and malaria (34 [24%]). 134 (96%) caregivers were patients' mothers. Clinician visits/hour increased with patients' illness severity in both arms, but without difference in frequency between arms (point estimate for difference -0.9%, p = 0.97). Of the 16 deaths, 8 (four/arm) occurred within 2 days of enrollment. Forty clinicians were surveyed, 33 (82%) reporting that FASTER could improve outcomes of very sick children in low-resource settings; 26 (65%) rating caregivers as able to adequately capture patients' severity of illness. Of 70 caregivers surveyed, 63 (90%) reported that FASTER training was easy to understand; all (100%) agreed that the intervention would improve care of hospitalized children and help identify sick children in their community.

DISCUSSION

We observed no difference in recorded frequency of clinician visits with FASTER monitoring. However, the tool was rated positively by caregivers and clinicians., Implementation appears feasible but requires optimization. These feasibility data may inform a larger trial powered to measure morbidity and mortality outcomes to determine the utility of FASTER in detecting and responding to clinical deterioration in low-resource settings.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT03513861.