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Ikeda S, Aoyanagi M, Nakaya R, Yoshimura M, Sumi N. Factors Related to Person-Centered Care for Older Patients With Cancer and Dementia in Designated Cancer Hospitals. Cancer Nurs 2024:00002820-990000000-00222. [PMID: 38442015 DOI: 10.1097/ncc.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
BACKGROUND Person-centered care (PCC) should be promoted for patients with cancer and dementia who are likely to be hindered from pursuing a meaningful life owing to their will not being reflected in the cancer treatment process. OBJECTIVE This study aimed to clarify the factors related to nurses' practice of PCC for older patients with cancer and dementia in designated cancer hospitals. METHODS An online cross-sectional survey was administered to nurses working at designated cancer hospitals in Japan. The survey items included demographic data and factors assumed to be related to nursing practice and practice of PCC. RESULTS A multiple regression analysis indicated that the factors related to the practice of PCC were attitude toward patients with dementia (β = 0.264, P < .001), holding conferences (β = 0.255, P < .001), knowledge about cancer nursing (β = 0.168, P < .001), knowledge about dementia (β = 0.128, P = .003), and participation in dementia care training (β = 0.088, P = .032). CONCLUSIONS Nurses' practice of PCC may not be sufficient to provide personalized care tailored to patients' cognitive function. The factors related to PCC are attitude toward patients with dementia, holding conferences, knowledge about cancer and dementia, and dementia care training. IMPLICATIONS FOR PRACTICE To promote PCC for patients with cancer and dementia, nurses should learn about these conditions with an interest in patients and collaborate with other professionals. Future studies should use cluster sampling and focus on the extent of cancer or dementia symptoms.
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Affiliation(s)
- Setsuka Ikeda
- Author Affiliations: KKR Sapporo Medical Center (Ms Ikeda); School of Health Sciences, Sapporo Medical University (Dr Aoyanagi); Hokkaido University Hospital (Mr Nakaya); Faculty of Health Sciences, Japan Health Care University (Ms Yoshimura); and Faculty of Health Sciences, Hokkaido University (Dr Sumi), Japan
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2
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Bryant J, Mansfield E, Cameron E, Sanson-Fisher R. Experiences and preferences for advance care planning following a diagnosis of dementia: Findings from a cross-sectional survey of carers. PLoS One 2023; 18:e0286261. [PMID: 37307258 DOI: 10.1371/journal.pone.0286261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Future medical and financial planning is important for persons with dementia given the impact of the disease on capacity for decision making. AIMS To explore from the perspective of carers of persons with dementia: (1) Participation in future medical and financial planning by the person they care for, including when planning was undertaken and the characteristics associated with having an advance care directive completed; (2) The type of healthcare providers who discussed advance care planning following diagnosis; and (3) Preferences for timing of discussions about advance care planning following diagnosis. METHODS Recruitment and data collection took place between July 2018 and June 2020. Carers of persons with dementia aged 18 years and older were mailed a survey. Participants completed questions regarding completion of various future planning documents by the person they support, including time of completion and who discussed advance care planning following diagnosis. Participants were presented with information about the benefits and consequences of early and late discussions of advance care planning and asked when discussions about advance care planning were best initiated. RESULTS 198 carers participated. Most participants were female (74%) and had been a carer for more than 2 years (82%). Most participants reported that the person with dementia they support had made a Will (97%) and appointed an Enduring Guardian (93%) and Enduring Power of Attorney (89%). Only 47% had completed an advance care directive. No significant associations were found between characteristics of persons with dementia and completion of an advance care directive. Geriatricians (53%) and GPs (51%) most often discussed advance care planning following diagnosis. Most carers thought that discussions about advance care planning should occur in the first few weeks or months following diagnosis (32%), at the healthcare provider's discretion (31%), or at the time of diagnosis (25%). CONCLUSIONS More than half of persons with dementia do not have an advance care directive. There is variability in preferences for timing of discussions following dementia diagnosis.
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Affiliation(s)
- Jamie Bryant
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Elise Mansfield
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Emilie Cameron
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Rob Sanson-Fisher
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, Australia
- Equity in Health and Wellbeing Program, Hunter Medical Research Institute, New Lambton Heights, Australia
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3
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Gabbard J, Strahley AE, Pajewski NM, Callahan KE, Foley KL, Brown A, Moses A, Kirkendall E, Williamson JD, Brooten J, Marterre B, Sutfin EL. Development of an Advance Care Planning Portal-Based Tool for Community-Dwelling Persons Living With Cognitive Impairment: The ACPVoice Tool. Am J Hosp Palliat Care 2022:10499091221134030. [PMID: 36239407 PMCID: PMC10102257 DOI: 10.1177/10499091221134030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Patient portals can be an innovative and efficient way to engage patients in advance care planning (ACP). However, comprehension and judgment in older adults with cognitive impairment presents several barriers and challenges to engaging in new technology. Our objective was to develop an ACP portal-based tool (ACPVoice) for community-dwelling persons living with cognitive impairment (PLCI) by engaging end-users in the design process. Methods: Two rounds of cognitive interviews were conducted to identify and resolve cognitive issues related to comprehension, judgment, response, and to assess content validity. Purposive sampling was used with the goal of enrolling 15 different participants (five with mild cognitive impairment and five dyads (those with mild dementia and their care partner) in each round to assess respondents' understanding of questions related to advance care planning to be administered via the patient portal. Results: Twenty PLCI (mean age 78.4, 10 females [50%]) and ten care partners (mean age 60.9, 9 females [90%]) completed cognitive interviews between May 2021 and October 2021. The mean Mini-Mental State Examination score for PLCI was 25.6 (SD 2.6). Unclear wording and undefined vague and/or unfamiliar terms were the major issues identified. Revisions to item wording, response options, and instructions were made to improve question comprehension and response as well as navigational ease. Conclusion: Minor changes to the wording, format, and response options substantially improved respondents' ability to interpret the item content of the ACPVoice tool. Dissemination and implementation of the ACPVoice tool could help to engage community-dwelling PLCI in ACP discussions.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ashley E Strahley
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nicholas M Pajewski
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Biostatistics and Data Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Kristie L Foley
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Implementation Science, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew Brown
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Adam Moses
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Section on General Internal Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Eric Kirkendall
- Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Pediatrics, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Center for Healthcare Innovation, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Justin Brooten
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Department of Emergency Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Buddy Marterre
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Erin L Sutfin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, 12279Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Integration of a Palliative Approach in the Care of Older Adults with Dementia in Primary Care Settings: A Scoping Review. Can J Aging 2021; 41:404-420. [PMID: 34743774 DOI: 10.1017/s0714980821000349] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A palliative approach to care aims to meet the needs of patients and caregivers throughout a chronic disease trajectory and can be delivered by non-palliative specialists. There is an important gap in understanding the perspectives and experiences of primary care providers on an integrated palliative approach in dementia care and the impact of existing programs and models to this end. To address these, we undertook a scoping review. We searched five databases; and used descriptive numerical summary and narrative synthesizing approaches for data analysis. We found that: (1) difficulty with prognostication and a lack of interdisciplinary and intersectoral collaboration are obstacles to using a palliative approach in primary care; and (2) a palliative approach results in statistically and clinically significant impacts on community-dwelling individuals, specifically those with later stages of dementia. There is a need for high-quality research studies examining the integrated palliative approach models and initiation of these models sooner in the care trajectory for persons living with mild and moderate stages of dementia in the community.
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5
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Leniz J, Higginson IJ, Yi D, Ul-Haq Z, Lucas A, Sleeman KE. Identification of palliative care needs among people with dementia and its association with acute hospital care and community service use at the end-of-life: A retrospective cohort study using linked primary, community and secondary care data. Palliat Med 2021; 35:1691-1700. [PMID: 34053356 PMCID: PMC8532216 DOI: 10.1177/02692163211019897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital admissions among people dying with dementia are common. It is not known whether identification of palliative care needs could help prevent unnecessary admissions. AIM To examine the proportion of people with dementia identified as having palliative care needs in their last year of life, and the association between identification of needs and primary, community and hospital services in the last 90 days. DESIGN Retrospective cohort study using Discover, an administrative and clinical dataset from 365 primary care practices in London with deterministic individual-level data linkage to community and hospital records. SETTING/PARTICIPANTS People diagnosed with dementia and registered with a general practitioner in North West London (UK) who died between 2016 and 2019. The primary outcome was multiple non-elective hospital admissions in the last 90 days of life. Secondary outcomes included contacts with primary and community care providers. We examined the association between identification of palliative care needs with outcomes. RESULTS Among 5804 decedents with dementia, 1953 (33.6%) were identified as having palliative care needs, including 1141 (19.7%) identified before the last 90 days of life. Identification of palliative care needs before the last 90 days was associated with a lower risk of multiple hospital admissions (Relative Risk 0.70, 95% CI 0.58-0.85) and more contacts with the primary care practice, community nurses and palliative care teams in the last 90 days. CONCLUSIONS Further investigation of the mechanisms underlying the association between identification of palliative care needs and reduced hospital admissions could help reduce reliance on acute care for this population.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Zia Ul-Haq
- Discover-Now, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-Now, Imperial College Health Partners, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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6
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Filteau C, Simeone A, Ravot C, Dayde D, Falandry C. Cultural and Ethical Barriers to Cancer Treatment in Nursing Homes and Educational Strategies: A Scoping Review. Cancers (Basel) 2021; 13:3514. [PMID: 34298728 PMCID: PMC8305927 DOI: 10.3390/cancers13143514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 01/15/2023] Open
Abstract
(1) Background: The aging of the population, the increase in the incidence of cancer with age, and effective chronic oncological treatments all lead to an increased prevalence of cancer in nursing homes. The aim of the present study was to map the cultural and ethical barriers associated with the treatment of cancer and educational strategies in this setting. (2) Methods: A systematic scoping review was conducted until April 2021 in MEDLINE, Embase, and CINAHL. All articles assessing continuum of care, paramedical education, and continuing education in the context of older cancer patients in nursing homes were reviewed. (3) Results: A total of 666 articles were analyzed, of which 65 studies were included. Many factors interfering with the decision to investigate and treat, leading to late- or unstaged disease, palliative-oriented care instead of curative, and a higher risk of unjustified transfers to acute care settings, were identified. The educational strategies explored in this context were generally based on training programs. (4) Conclusions: These results will allow the co-construction of educational tools intended to develop knowledge and skills to improve diagnostic and therapeutic decision-making, the consistency of care, and, ultimately, the quality of life of older cancer patients in nursing homes.
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Affiliation(s)
- Cynthia Filteau
- Service de Gériatrie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France; (C.R.); (C.F.)
- Département de Gériatrie, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC H1T 2M4, Canada
| | - Arnaud Simeone
- Université Lumière-Groupe de Recherche en Psychologie Sociale (UR GRePS) Institut de Psychologie, 69676 Bron, France;
| | - Christine Ravot
- Service de Gériatrie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France; (C.R.); (C.F.)
| | - David Dayde
- Plateforme de Recherche de l’Institut de Cancérologie des Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France;
| | - Claire Falandry
- Service de Gériatrie, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France; (C.R.); (C.F.)
- Laboratoire CarMeN, INSERM, INRAE, Université Claude Bernard Lyon-1, 69600 Oullins, France
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7
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Zemplényi AT, Csikós Á, Fadgyas-Freyler P, Csanádi M, Kaló Z, Pozsgai É, Rutten-van Mölken M, Pitter JG. Early palliative care associated with lower costs for adults with advanced cancer: evidence from Hungary. Eur J Cancer Care (Engl) 2021; 30:e13473. [PMID: 34106508 DOI: 10.1111/ecc.13473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 03/12/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Palliative Care Consult Service (PCCS) programme was established in Hungary to provide palliative care to hospitalised patients with complex needs and to coordinate integrated care across providers. The aim of this study was to measure the association of PCCS with healthcare costs from payer's perspective. METHODS Study population consisted of patients with metastatic cancer, who were admitted to the Clinical Centre of the University of Pécs between 2014 and 2016. Patients who did not die within 180 days from enrolment were excluded. Patients receiving services from PCCS team (intervention patients) were compared to patients receiving usual care (controls). The two populations were matched using propensity scores. Data were obtained from electronic medical records linked to claims data. RESULTS For patients who were involved in PCCS at least 60 days before their death, the costs of care outside the acute hospital were higher. However, this was offset by savings in hospital costs so that the total healthcare cost was significantly reduced (p = 0.034). The proportion of patients who died in the hospital was lower in the PCCS group compared to the usual care group (66% vs. 85%, p = 0.022). CONCLUSION Timely initiation of palliative care for hospitalised patients is associated with cost savings for the healthcare system.
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Affiliation(s)
- Antal Tamás Zemplényi
- Division of Pharmacoeconomics, Faculty of Pharmacy, University of Pécs, Pécs, Hungary.,Syreon Research Institute, Budapest, Hungary
| | - Ágnes Csikós
- Institute of Primary Health Care, University of Pécs Medical School, Pécs, Hungary
| | | | | | - Zoltán Kaló
- Syreon Research Institute, Budapest, Hungary.,Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Éva Pozsgai
- Institute of Primary Health Care, University of Pécs Medical School, Pécs, Hungary
| | - Maureen Rutten-van Mölken
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Davies N, De Souza T, Rait G, Meehan J, Sampson EL. Developing an applied model for making decisions towards the end of life about care for someone with dementia. PLoS One 2021; 16:e0252464. [PMID: 34043728 PMCID: PMC8158904 DOI: 10.1371/journal.pone.0252464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. AIM Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. METHODS Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018-2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. RESULTS Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. CONCLUSIONS The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Tanisha De Souza
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Greta Rait
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Jessica Meehan
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Elizabeth L. Sampson
- Centre for Dementia Palliative Care Research, Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, United Kingdom
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9
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Bernstein Sideman A, Harrison KL, Garrett SB, Naasan G, Ritchie CS. Practices, challenges, and opportunities when addressing the palliative care needs of people living with dementia: Specialty memory care provider perspectives. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12144. [PMID: 33969177 PMCID: PMC8087986 DOI: 10.1002/trc2.12144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Palliative care focuses on reducing suffering and improving quality of life for individuals with serious illness and their families. In an effort to develop palliative care interventions for specialty memory care clinics, this study characterizes memory care providers' perspectives on addressing palliative care needs of people living with dementia (PLWD). METHODS Qualitative interviews with specialty memory care providers were followed by thematic analysis by a multidisciplinary research team. RESULTS Provider approaches overlap with key domains of palliative care. Approaches unique to dementia include having a detailed understanding of dementia syndromes, behavioral symptoms, and caregiver burden. Challenges were identified related to disease progression, provider-level factors, and systems and cultural issues. Respondents identified training needed to strengthen a palliative care approach. DISCUSSION There are many strengths of using memory care teams to address palliative care needs of PLWD. However, they may require additional knowledge and training to strengthen their work.
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Affiliation(s)
- Alissa Bernstein Sideman
- Philip R. Lee Institute for Health Policy StudiesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Global Brain Health InstituteUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Department of Humanities and Social SciencesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Krista L. Harrison
- Global Brain Health InstituteUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sarah B. Garrett
- Philip R. Lee Institute for Health Policy StudiesUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Georges Naasan
- NeurologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
- Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Christine S. Ritchie
- Global Brain Health InstituteUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
- Division of Palliative Care and Geriatric MedicineHarvard Medical SchoolBostonMassachusettsUSA
- Mongan Institute Center for Aging and Serious IllnessMassachusetts General HospitalBostonMassachusettsUSA
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Szilcz M, Wastesson JW, Johnell K, Morin L. Unplanned hospitalisations in older people: illness trajectories in the last year of life. BMJ Support Palliat Care 2021:bmjspcare-2020-002778. [PMID: 33906860 DOI: 10.1136/bmjspcare-2020-002778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/14/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Unplanned hospitalisations can be burdensome for older people who approach the end of life. Hospitalisations disrupt the continuity of care and often run against patients' preference for comfort and palliative goals of care. This study aimed to describe the patterns of unplanned hospitalisations across illness trajectories in the last year of life. METHODS Longitudinal, retrospective cohort study of decedents, including all older adults (≥65 years) who died in Sweden in 2015. We used nationwide data from the National Cause of Death Register linked at the individual level with several other administrative and healthcare registers. Illness trajectories were defined based on multiple-cause-of-death data to approximate functional decline near the end of life. Incidence rate ratios (IRR) for unplanned hospitalisations were modelled with zero-inflated Poisson regressions. RESULTS In a total of 77 315 older decedents (53% women, median age 85.2 years), the overall incidence rate of unplanned hospitalisations during the last year of life was 175 per 100 patient-years. The adjusted IRR for unplanned hospitalisation was 1.20 (95%CI 1.18 to 1.21) times higher than average among decedents who followed a trajectory of cancer. Conversely, decedents who followed the trajectory of prolonged dwindling had a lower-than-average risk of unplanned hospitalisation (IRR 0.66, 95% CI 0.65 to 0.68). However, these differences between illness trajectories only became evident during the last 3 months of life. CONCLUSION Our study highlights that, during the last 3 months of life, unplanned hospitalisations are increasingly frequent. Policies aiming to reduce burdensome care transitions should consider the underlying illness trajectories.
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Affiliation(s)
- Máté Szilcz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas W Wastesson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lucas Morin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Inserm CIC 1431, University Hospital of Besançon, Besançon, France
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11
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Discordance between the perceptions of clinicians and families about end-of-life trajectories in hospitalized dementia patients. Palliat Support Care 2021; 19:304-311. [PMID: 33821781 DOI: 10.1017/s1478951521000109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Due to the unpredictable dementia trajectory, it is challenging to recognize illness progression and the appropriateness of a palliative approach. Further confusion occurs during hospitalization where the presence of comorbid conditions complicates prognostication. This research examined clinicians and families' perceptions of dementia as a terminal condition in relation to end-of-life admissions. CONTEXT The study was based in the General Medicine units of one Australian public hospital. Medical, nursing, and social work clinicians were recruited to reflect multidisciplinary perspectives. Bereaved caregivers of deceased patients with dementia were interviewed 3 months following death. METHODS Qualitative research underpinned by a social constructionist epistemology and framed through complex systems theory. Semi-structured interviews generated data that illuminated perceptions of deterioration observed toward the end of life. RESULTS Although participants anticipated general cognitive and physical deterioration associated with dementia, the emergence of comorbid illness made it difficult to predict the onset of the end of life. During a hospital admission, clinicians attributed the end of life to the advanced outcomes of dementia, whereas families described new medical crises. End-of-life admissions illuminated intersections between dementia and comorbidities rather than illness progression. In contrast with the perception that people with dementia lose awareness at the end of life, families drew attention to evidence that their loved one was present during the dying phase. SIGNIFICANCE OF RESULTS Our findings challenge the dominant understanding of dementia trajectories. Bifurcations between clinicians and families' views demonstrate the difficulties in recognizing end-of-life transitions. Implications for the integration of palliative care are considered.
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Lundin E, Godskesen TE. End-of-life care for people with advanced dementia and pain: a qualitative study in Swedish nursing homes. BMC Nurs 2021; 20:48. [PMID: 33743691 PMCID: PMC7981921 DOI: 10.1186/s12912-021-00566-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/11/2021] [Indexed: 11/25/2022] Open
Abstract
Background Of the Swedish people with advanced dementia, the majority die in nursing homes. Unresolved pain can occur in people with a terminal illness such as dementia. However, pain management in people with advanced dementia is often suboptimal and inadequate, with fewer palliative care interventions than offered to cancer patients. Although they are largely responsible for the care of these people, few studies have addressed the experiences of registered nurses in this respect. Therefore, the aim of this study was to describe the experiences of nurses in caring for people with advanced dementia and pain at the end of life. Methods The study had a descriptive explorative design. Individual qualitative, semi-structured interviews were carried out with 13 nurses from 12 nursing homes in Sweden. The results were analysed using thematic content analysis. Results The nurses described communicative, relational and organisational challenges. One major issue involved difficulties communicating with the person with advanced dementia, resulting in uncertain pain assessment. Other difficulties involved the differentiation of pain from anxiety, the balance of benefits and risks with morphine administration, and the creation of good relationships with healthcare personnel and the persons’ relatives. Relatives can greatly affect the assessment and management of pain, both because of their ability to interpret pain behaviour and by questioning the care given. Good pain management was facilitated by good communication and relationships with healthcare staff and relatives, extensive professional nursing experience, and already knowing the person with advanced dementia. Conclusions This study highlights the need for nursing homes to employ specialist nurses who have been trained in the appropriate knowledge and skills to deal with the challenges of end-of-life care for people with advanced dementia and pain. Additionally, there should be resources and strategies available for providing information to family members and for involving them in the decision-making process, as they are often unfamiliar with the multitude of considerations involved in decisions such as whether to administer morphine or not. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-021-00566-7.
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Affiliation(s)
- Emma Lundin
- Nacka Senior Centre Talliden, Helgesons väg 5, SE-131 37, Nacka, Sweden
| | - Tove E Godskesen
- Centre for Research Ethics & Bioethics, Uppsala University, BMC, Box 564, SE-751 22, Uppsala, Sweden. .,Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Box 11189, SE-100 61, Stockholm, Sweden.
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Oh SN, Kim YA, Kim YJ, Shim HJ, Song EK, Kang JH, Kwon JH, Lee JL, Lee SN, Maeng CH, Kang EJ, Do YR, Yun HJ, Jung KH, Yun YH. The Attitudes of Physicians and the General Public toward Prognostic Disclosure of Different Serious Illnesses: a Korean Nationwide Study. J Korean Med Sci 2020; 35:e401. [PMID: 33289368 PMCID: PMC7721562 DOI: 10.3346/jkms.2020.35.e401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/14/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although international guidelines recommend palliative care approaches for many serious illnesses, the palliative needs of patients with serious illnesses other than cancer are often unmet, mainly due to insufficient prognosis-related discussion. We investigated physicians' and the general public's respective attitudes toward prognostic disclosure for several serious illnesses. METHODS We conducted a cross-sectional survey of 928 physicians, sourced from 12 hospitals and the Korean Medical Association, and 1,005 members of the general public, sourced from all 17 administrative divisions in Korea. RESULTS For most illnesses, most physicians (adjusted proportions - end-organ failure, 99.0%; incurable genetic or neurologic disease, 98.5%; acquired immune deficiency syndrome [AIDS], 98.4%; stroke or Parkinson's disease, 96.0%; and dementia, 89.6%) and members of the general public (end-organ failure, 92.0%; incurable genetic or neurologic disease, 92.5%; AIDS, 91.5%; stroke or Parkinson's disease, 92.1%; and dementia, 86.9%) wanted to be informed if they had a terminal prognosis. For physicians and the general public, the primary factor to consider when disclosing terminal status was "the patient's right to know his/her condition" (31.0%). Yet, the general public was less likely to prefer prognostic disclosure than physicians. Particularly, when their family members were patients, more than 10% of the general public did not want patients to be informed of their terminal prognosis. For the general public, the main reason for not disclosing prognosis was "psychological burden such as anxiety and depression" (35.8%), while for the physicians it was "disclosure would have no beneficial effect" (42.4%). CONCLUSION Most Physicians and the general public agreed that disclosure of a terminal prognosis respects patient autonomy for several serious illnesses. The low response rate of physicians might limit the generalizability of the results.
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Affiliation(s)
- Si Nae Oh
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Medicine, Yonsei University Graduate School, Seoul, Korea
| | - Young Ae Kim
- Hospice & Palliative Care Branch, National Cancer Control Institute, National Cancer Center, Goyang, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun Jeong Shim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Chonnam National University School of Medicine, Hwasun, Korea
| | - Eun Kee Song
- Division of Hematology/Oncology, Jeonbuk National University Medical School, Jeonju, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Lim Lee
- Department of Hemato-oncology, Daegu Fatima Hospital, Daegu, Korea
| | - Soon Nam Lee
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Chi Hoon Maeng
- Division of Medical Oncology and Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Eun Joo Kang
- Division of Medical Oncology, Department of Internal Medicine, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Young Rok Do
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Hwan Jung Yun
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ho Yun
- Department of Family Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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Armstrong MJ, Alliance S, Corsentino P, Maixner SM, Paulson HL, Taylor A. Caregiver-Reported Barriers to Quality End-of-Life Care in Dementia With Lewy Bodies: A Qualitative Analysis. Am J Hosp Palliat Care 2020; 37:728-737. [PMID: 31902223 PMCID: PMC7335680 DOI: 10.1177/1049909119897241] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study investigated barriers to quality end-of-life (EOL) care in the context of dementia with Lewy bodies (DLB), one of the most common degenerative dementias in the United States. METHODS The study consisted of telephone interviews with caregivers and family members of individuals who died with DLB in the last 5 years. Interviews used a semi-structured questionnaire. Investigators employed a qualitative descriptive approach to analyze interview transcripts and identify common barriers to quality EOL care. RESULTS Thirty participants completed interviews. Reported barriers to quality EOL experiences in DLB pertained to the DLB diagnosis itself and factors relating to the US health-care system, facilities, hospice, and health-care providers (physicians and staff). Commonly reported barriers included lack of recognition and knowledge of DLB, lack of education regarding what to expect, poor coordination of care and communication across health-care teams and circumstances, and difficulty accessing health-care resources including skilled nursing facility placement and hospice. CONCLUSION Many identified themes were consistent with published barriers to quality EOL care in dementia. However, DLB-specific EOL considerations included diagnostic challenges, lack of knowledge regarding DLB and resultant prescribing errors, difficulty accessing resources due to behavioral changes in DLB, and waiting to meet Medicare dementia hospice guidelines. Improving EOL experiences in DLB will require a multifaceted approach, starting with improving DLB recognition and provider knowledge. More research is needed to improve recognition of EOL in DLB and factors that drive quality EOL experiences.
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Affiliation(s)
- Melissa J. Armstrong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL
- McKnight Brain Institute, University of Florida, Gainesville, FL
| | - Slande Alliance
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL
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Gabbard J, Johnson D, Russell G, Spencer S, Williamson JD, McLouth LE, Ferris KG, Sink K, Brenes G, Yang M. Prognostic Awareness, Disease and Palliative Understanding Among Caregivers of Patients With Dementia. Am J Hosp Palliat Care 2020; 37:683-691. [PMID: 31854201 PMCID: PMC10581031 DOI: 10.1177/1049909119895497] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Persons with dementia (PwD) often have significant cognitive deficits and functional limitations, requiring substantial caregiver assistance. Given the high symptom burden and terminal nature of dementia, good prognostic awareness and integration of palliative care (PC) is needed. OBJECTIVE To evaluate prognostic awareness, disease, and PC understanding among caregivers of PwD and to assess for improvements in routine care. DESIGN A cross-sectional study of 2 cohorts at a single-academic medical center. Surveys were mailed to 200 caregivers of PwD in 2012 (cohort 1). Surveys were sent to new subset of caregivers of PwD (n = 80) in 2018 (cohort 2) to assess trends over time. RESULTS A total of 154 of caregivers completed the survey (response rate 55%). Compared to 2012, a higher proportion of caregivers in 2018 reported having conversations about prognosis with PwD's physicians (25% in 2012 vs 45% in 2018; P = .027). However, a large percentage (43% in 2012 and 40% in 2018) of caregivers reported no understanding of the PwD's prognosis. Despite most stating dementia was not curable, only 39% in 2012 and 52% in 2018 (P = .015) understood that dementia was a terminal disease. In addition, only 32% in 2012 and 40% in 2018 (P = .39) felt that they were knowledgeable about PC. CONCLUSIONS Prognostic discussions between caregivers of PwD and the PwD's physicians may be occurring more often; however, a high percentage of caregivers report a poor understanding about the terminal nature of dementia and the role of PC.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Devin Johnson
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Greg Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shenita Spencer
- Center for Supportive Care and Survivorship, Atrium Health, Charlotte, NC, USA
| | - Jeff D. Williamson
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laurie E. McLouth
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Keren G. Ferris
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaycee Sink
- Product Development—Neuroscience, Genentech Inc, South San Francisco, CA, USA
| | - Gretchen Brenes
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mia Yang
- Section on Gerontology & Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Mayo AM, Siegle K, Savell E, Bullock B, Preston GJ, Peavy GM. Lay Caregivers' Experiences With Caring for Persons With Dementia: A Phenomenological Study. J Gerontol Nurs 2020; 46:17-27. [PMID: 32491183 PMCID: PMC8915949 DOI: 10.3928/00989134-20200527-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/16/2020] [Indexed: 11/20/2022]
Abstract
Today, biomedical advancements allow older adults, including those with dementia, to live longer, with most living at home with a lay caregiver. Recent research details the stressful role of caregiving to persons with dementia (PWD). The current qualitative phenomenological study describes the lived experience of caregivers caring for PWD, including their experience with palliative care. A community sample of lay caregivers (N = 11) underwent recorded individual interviews. Interviews were analyzed following van Manen's approach to isolate thematic statements. Most caregivers were older (mean age = 71, SD = 9.6; range = 53 to 84 years) and female (n = 10). Study themes included: (a) Uncertainty: The Slippery Slope, (b) The Sense of Loneliness, (c) Complexities of Frustration, and (d) On the Other Side of the Spectrum. Findings show these caregivers are dealing with a dynamic range of feelings about their experiences. Opportunities exist for health care professionals to discuss such feelings and refer caregivers to supportive services, including palliative care. [Journal of Gerontological Nursing, 46(8), 17-27.].
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Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17145130. [PMID: 32708596 PMCID: PMC7400302 DOI: 10.3390/ijerph17145130] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals. Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed. Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public. Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients’ values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.
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Oliveira AEGD, Cury VE. A EXPERIÊNCIA DE PACIENTES ASSISTIDOS POR UM SERVIÇO DE ATENÇÃO DOMICILIAR (SAD). PSICOLOGIA EM ESTUDO 2020. [DOI: 10.4025/psicolestud.v25i0.44108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Apresentam-se os resultados de uma pesquisa de doutorado em psicologia, que buscou compreender, fenomenologicamente, a experiência de pacientes assistidos por um Serviço de Atenção Domiciliar (SAD), vinculado ao Sistema Único de Saúde (SUS), num município do Estado de São Paulo. A pesquisadora realizou encontros dialógicos individuais, mediados por uma questão norteadora, com sete pacientes adultos de ambos os sexos e a partir de suas impressões, escreveu narrativas compreensivas sobre a experiência de cada participante. Excertos dessas narrativas serão aqui apresentados, assim como os elementos essenciais da experiência de ser cuidado em casa. Concluiu-se que a vivência do cuidado em domicílio favorece a autonomia do paciente, possibilitando o convívio com os familiares e a manutenção de elementos identitários presentes na moradia. Como contribuição deste estudo, aponta-se que o espaço da casa, enquanto contexto de cuidado em saúde favorece relações interpessoais positivas entre a equipe de profissionais de saúde, pacientes e familiares, tornando-o potencialmente mais humanizador.
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Smith C, Newbury G. Palliative care for community patients diagnosed with dementia: a systematic review. Br J Community Nurs 2020; 24:570-575. [PMID: 31800308 DOI: 10.12968/bjcn.2019.24.12.570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite many efforts made by health organisations to deliver effective end-of-life care to patients with dementia, research indicates that palliative care is predominantly aimed at patients with terminal cancer, and that patients with dementia face challenges in accessing end-of-life care. This article explores the views of health professionals on providing palliative care to those patients diagnosed with dementia within the community setting. A systematic review of seven qualitative studies was performed to identify the best available evidence. The findings show that effective palliative care for patients with dementia continues being affected by many barriers and challenges. Good practice seems to be inconsistent and fragmented throughout the UK and European countries, and many health professionals are faced with difficulties associated with services and financial implications, training and education, staff support, communication, family support and dementia care.
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Affiliation(s)
| | - Gina Newbury
- Senior Lecturer and Director of Recruitment and Admissions, both at School of Healthcare Sciences, Cardiff University, Cardiff, Wales
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Mondejar-Pont M, Ramon-Aribau A, Gómez-Batiste X. Integrated palliative care definition and constitutive elements: scoping review. JOURNAL OF INTEGRATED CARE 2019. [DOI: 10.1108/jica-11-2018-0069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to propose a unified definition of integrated palliative care (IPC), and to identify the elements that facilitate or hinder implementation of an integrated palliative care system (IPCS).
Design/methodology/approach
A scoping review of the conceptualization and essential elements of IPC was undertaken, based on a search of the PubMed, Scopus and ISI Web of Science databases. The search identified 79 unduplicated articles; 43 articles were selected for content analysis.
Findings
IPC is coordinated and collaborative across different health organizations, levels of care and types of providers. Eight key elements facilitate implementation of an IPCS: coordination, early patient identification, patient-centered services, care continuity, provider education and training, a standard implementation model and screening tool, shared information technology system, and supportive policies and funding. These elements were plotted as a “Circle of Integrated Palliative Care System Elements.”
Practical implications
This paper offers researchers an inclusive definition of IPC and describes the essential elements of its successful implementation.
Originality/value
This study provides evidence from researchers on five continents, offering insights from multiple countries and cultures on the topic of IPC. The findings of this thematic analysis could assist international researchers aiming to develop a standard evaluative model or assess the level of integration in a health care system’s delivery of palliative care.
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Davies N, Hopwood J, Walker N, Ross J, Iliffe S, Walters K, Rait G. Designing and developing a co-produced theoretical and evidence-based online support for family caregivers of people with dementia at the end of life. BMC Palliat Care 2019; 18:71. [PMID: 31409329 PMCID: PMC6693100 DOI: 10.1186/s12904-019-0455-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Caring for someone with dementia can be physically and emotionally difficult. Acting as a caregiver can make it difficult to access sources of support, particularly in the later stages of dementia. This paper reports the development and presents the targets (subject areas) and components of a prototype website to support family caregivers of a person with dementia towards the end of life. METHODS Adopting an iterative approach and co-production methods the development process consisted of four stages: Stage1-Synthesis of data: three sources of data (interviews, systematic review and theory) were synthesised using tabulation, to identify the targets of the prototype; Stage2-Identifying intervention targets and components: a research development group (health practitioners, a family caregiver and academic experts) met to discuss the development, using a modified nominal group process, refining the synthesis from stage 1; Stage3-Developing the intervention prototype: an outline of the prototype was developed based on stage 1 and 2; and Stage4-User testing: interviews with caregivers testing the prototype website. RESULTS Qualitative interviews with caregivers identified four targets for the intervention: 1) feeling prepared and equipped; 2) feeling connected and supported; 3) valuing themselves as a caregiver and as an individual; 4) maintaining control of the caring situation and being the coordinator of care. The systematic review provided evidence on how and what components could address these targets, including providing information, peer support, contact with professionals, and psychological support. Theory helped to narrow the focus within each of these targets. Active discussion with the research development group and end users provided an outline of the prototype website. The prototype website presented addresses these targets with written information, videos from other caregivers, and peer and professional support sections. The subject areas covered included expectations at the end of life, support with day-to-day caring, care planning, and communication. CONCLUSIONS This paper provides a detailed account of the development process of a prototype website for caregiver support. The transparent methodology and key lessons learnt from developing the prototype should help those who are developing similar interventions, across complex, progressive conditions and not just limited to dementia.
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Affiliation(s)
- Nathan Davies
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
- Centre for Dementia Palliative Care Research, Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Jenny Hopwood
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Nina Walker
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Jamie Ross
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Steve Iliffe
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Kate Walters
- Centre for Ageing Population Studies, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
| | - Greta Rait
- Priment Clinical Trials Unit, Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London, NW3 2PF UK
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Boyd M, Frey R, Balmer D, Robinson J, McLeod H, Foster S, Slark J, Gott M. End of life care for long-term care residents with dementia, chronic illness and cancer: prospective staff survey. BMC Geriatr 2019; 19:137. [PMID: 31117991 PMCID: PMC6532195 DOI: 10.1186/s12877-019-1159-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/14/2019] [Indexed: 11/10/2022] Open
Abstract
Background Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. Methods After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident’s death. Results Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. Conclusions Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.
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Affiliation(s)
- Michal Boyd
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand. .,Freemasons' Department of Geriatric Medicine, The University of Auckland, Auckland, New Zealand.
| | - Rosemary Frey
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Deborah Balmer
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Jackie Robinson
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Heather McLeod
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Susan Foster
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Julia Slark
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
| | - Merryn Gott
- School of Nursing, The University of Auckland, Private Bag, Auckland, 92019, New Zealand
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Mataqi M, Aslanpour Z. Factors influencing palliative care in advanced dementia: a systematic review. BMJ Support Palliat Care 2019; 10:145-156. [DOI: 10.1136/bmjspcare-2018-001692] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/23/2019] [Accepted: 03/06/2019] [Indexed: 12/31/2022]
Abstract
BackgroundDementia is a progressive neurodegenerative life-limiting disease. The international literature indicates that patients with advanced dementia can benefit from palliative care (PC) provided during the end-of-life phase. However, evidence indicates that currently many fail to access such provision despite the increased recognition of their palliative needs.AimTo investigate the factors influencing provision of PC services for people with advanced dementia.MethodsA systematic review of mixed method studies written in English was undertaken. 11 electronic databases including Embase, Medline, PubMed, CINAHL and Scopus from 2008 to 2018 were searched. Narrative synthesis and content analysis were used to analyse and synthesise the data.Key findingsIn total, 34 studies were included. 25 studies providing qualitative data, 6 providing quantitative data and 3 mixed methods studies. The findings identified organisational, healthcare professionals and patients-related barriers and facilitators in provision of PC for people with advanced dementia from perspective of stakeholders across different care settings. The most commonly reported barriers are lack of skills and training opportunities of the staff specific to PC in dementia, lack of awareness that dementia is a terminal illness and a palliative condition, pain and symptoms assessment/management difficulties, discontinuity of care for patients with dementia and lack of coordination across care settings, difficulty communicating with the patient and the lack of advance care planning.ConclusionsEven though the provision of PC was empirically recognised as a care step in the management of dementia, there are barriers that hinder access of patients with dementia to appropriate facilities. With dementia prevalence rising and no cure on the horizon, it is crucial that health and social care regulatory bodies integrate a palliative approach into their care using the identified facilitators to achieve optimal and effective PC in this population.
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Bamford C, Lee R, McLellan E, Poole M, Harrison-Dening K, Hughes J, Robinson L, Exley C. What enables good end of life care for people with dementia? A multi-method qualitative study with key stakeholders. BMC Geriatr 2018; 18:302. [PMID: 30514221 PMCID: PMC6280541 DOI: 10.1186/s12877-018-0983-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND People with advanced dementia often experience suboptimal end of life care (EoLC) with inadequate pain control, increased hospitalisation, and fewer palliative care interventions compared to those with cancer. Existing policy, guidance and recommendations are based largely on expert opinion because of a shortage of high quality, empirical research. Previous studies have tended to consider the views and experience of particular groups. Whilst providing important evidence, they do not take into account the diversity of perspectives of different stakeholders. The Supporting Excellence in End of life care in Dementia (SEED) programme involved multiple stakeholder groups and an integrative analysis to identify key components of good EoLC for people with dementia and to inform a new intervention. METHODS The views of national experts, service managers, frontline staff, people with dementia and family carers were explored using a range of qualitative methods (semi-structured interviews, focus groups, discussions and observations of routine care). The large dataset comprises 116 interviews, 12 focus groups and 256 h of observation. Each dataset was initially analysed thematically prior to an integrative analysis, which drew out key themes across stakeholder groups. RESULTS Through the integrative analysis seven key factors required for the delivery of good EoLC for people with dementia were identified: timely planning discussions; recognition of end of life and provision of supportive care; co-ordination of care; effective working relationships with primary care; managing hospitalisation; continuing care after death; and valuing staff and ongoing learning. These factors span the entire illness trajectory from planning at a relatively early stage in the illness to continuing care after death. CONCLUSIONS This unique study has confirmed the relevance of much of the content of existing end of life frameworks to dementia. It has highlighted seven key areas that are particularly important in dementia care. The data are being used to develop an evidence-based intervention to support professionals to deliver better EoLC in dementia.
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Affiliation(s)
- Claire Bamford
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Richard Lee
- Department of Social Work, Education and Community Wellbeing, Faculty of Health & Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Emma McLellan
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Marie Poole
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | | | - Julian Hughes
- Bristol Medical School, Population and Health Sciences, University of Bristol, Bristol, BS8 2PS UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Catherine Exley
- Health and Life Sciences, Northumbria University, Room NB266, Northumberland Building, College Street, Newcastle upon Tyne, NE1 8ST UK
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Hill E, Savundranayagam MY, Zecevic A, Kloseck M. Staff Perspectives of Barriers to Access and Delivery of Palliative Care for Persons With Dementia in Long-Term Care. Am J Alzheimers Dis Other Demen 2018; 33:284-291. [PMID: 29554814 PMCID: PMC10852501 DOI: 10.1177/1533317518765124] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dementia is a syndrome that is progressive, degenerative, and terminal. The palliative care philosophy aims to maximize quality of life for the dying individual and is both beneficial for and underused with persons dying with dementia. OBJECTIVES The purpose of this study was to investigate the experiences of long-term care staff delivering palliative care to individuals with dementia to determine how care was delivered, to learn which guidelines were used, and whether policies affected the delivery of palliative care. METHODS Twenty-two staff participants were interviewed. Their experiences were interpreted using phenomenological methodology. RESULTS Findings yielded 3 key themes: confusion, resource shortages, and communication difficulties. CONCLUSION Implications for practice include clarification of terminology surrounding palliative care, education of families about dementia and palliative care, better resource management, and the need to address when palliative care best fits within the dementia process.
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Affiliation(s)
- Emily Hill
- Faculty of Law, Western University, London, Ontario, Canada
| | - Marie Y. Savundranayagam
- Faculty of Health Sciences, School of Health Studies, Western University, London, Ontario, Canada
| | - Aleksandra Zecevic
- Faculty of Health Sciences, School of Health Studies, Western University, London, Ontario, Canada
| | - Marita Kloseck
- Faculty of Health Sciences, School of Health Studies, Western University, London, Ontario, Canada
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Lee EE, Chang B, Huege S, Hirst J. Complex Clinical Intersection: Palliative Care in Patients with Dementia. Am J Geriatr Psychiatry 2018; 26:224-234. [PMID: 28822692 PMCID: PMC5747550 DOI: 10.1016/j.jagp.2017.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/19/2017] [Indexed: 11/17/2022]
Abstract
Because of the rapidly growing older population and increases in longevity, rates of dementia have been rising. Clinical challenges of treating dementia include limited resources and lack of curative therapies. Palliative care approaches improve quality of life and alleviate suffering for dementia patients at the end of life, although implementation may be limited by societal acceptance and feasibility. This review examines the published literature on pain assessments, pain and behavior interventions, tools for advanced care planning, and clinical concerns in dementia patients. Ultimately, modification of the traditional palliative care model may improve outcomes and functioning for dementia patients at all stages of their illness.
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Affiliation(s)
- Ellen E Lee
- Department of Psychiatry, University of California San Diego, La Jolla, CA; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA.
| | - Beverly Chang
- Department of Psychiatry, University of California San Diego, La Jolla, CA; Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Steven Huege
- Department of Psychiatry, University of California San Diego, La Jolla, CA; Veterans Affairs San Diego Healthcare System, San Diego, CA
| | - Jeremy Hirst
- Department of Psychiatry, University of California San Diego, La Jolla, CA; Doris Howell Palliative Care Service, University of California San Diego, La Jolla, CA
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Nilsen P, Wallerstedt B, Behm L, Ahlström G. Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory. Implement Sci 2018; 13:1. [PMID: 29301543 PMCID: PMC5753464 DOI: 10.1186/s13012-017-0699-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 12/13/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes. METHODS Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care. RESULTS Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care. CONCLUSIONS There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual- and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.
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Affiliation(s)
- Per Nilsen
- Department of Medical and Health Sciences, Division of Community Medicine, Linköping University, SE-581 83, Linköping, Sweden.
| | - Birgitta Wallerstedt
- Department of Health and Care Sciences, Linnaeus University, SE-392 81, Kalmar, Sweden
| | - Lina Behm
- Department of Health Sciences, Faculty of Medicine, Lund University, PO Box 157, SE-221 00, Lund, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, PO Box 157, SE-221 00, Lund, Sweden
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Hill SR, Mason H, Poole M, Vale L, Robinson L. What is important at the end of life for people with dementia? The views of people with dementia and their carers. Int J Geriatr Psychiatry 2017; 32:1037-1045. [PMID: 27515899 DOI: 10.1002/gps.4564] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/12/2016] [Accepted: 07/14/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Approaching end of life is often a time of vulnerability; this is particularly so for people with dementia and their families where loss of capacity and the ability to communicate, make assessment and shared decision-making difficult. Research has consistently shown that improvements in care and services are required to support better quality and more person-centred care for people with dementia towards and at end of life. However, the views of people with dementia about what factors contribute to high-quality care at this time are a neglected area. AIM The aim of this study was to identify the aspects of end-of-life care for people with dementia that are most important to them and their carers. DESIGN Q-methodology, a mixed method combining qualitative and quantitative techniques to study subjectivity, was used to identify the views of people with mild dementia, their family carers and bereaved carers on end-of-life care for people with dementia. Fifty-seven participants were included in the study. RESULTS Four distinct views were identified: family involvement, living in the present, pragmatic expectations and autonomy and individuality. Some areas of consensus across all views included compassionate care, decisions being made by healthcare professionals and information availability when making decisions. CONCLUSION Our findings reveal several different views on what is important about end-of-life care for people with dementia; therefore, a 'one-size-fits-all' approach to care is unlikely to be most appropriate. Notwithstanding the differing viewpoints could provide a framework for service providers and commissioners for future care. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Marie Poole
- Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Newcastle University, Newcastle upon Tyne, UK
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29
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Lee RP, Bamford C, Poole M, McLellan E, Exley C, Robinson L. End of life care for people with dementia: The views of health professionals, social care service managers and frontline staff on key requirements for good practice. PLoS One 2017. [PMID: 28622379 PMCID: PMC5473529 DOI: 10.1371/journal.pone.0179355] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Evidence consistently shows that people with advanced dementia experience suboptimal end of life care compared to those with cancer; with increased hospitalisation, inadequate pain control and fewer palliative care interventions. Understanding the views of those service managers and frontline staff who organise and provide care is crucial in order to develop better end of life care for people with dementia. Methods and findings Qualitative interviews and focus groups were conducted from 2013 to 2015 with 33 service managers and 54 staff involved in frontline care, including doctors, nurses, nursing and care home managers, service development leads, senior managers/directors, care assistants and senior care assistants/team leads. All were audio recorded and transcribed verbatim. Participants represented a diverse range of service types and occupation. Transcripts were subject to coding and thematic analysis in data meetings. Analysis of the data led to the development of seven key themes: Recognising end of life (EOL) and tools to support end of life care (EOLC), Communicating with families about EOL, Collaborative working, Continuity of care, Ensuring comfort at EOL, Supporting families, Developing and supporting staff. Each is discussed in detail and comprise individual and collective views on approaches to good end of life care for people with dementia. Conclusions The significant challenges of providing good end of life care for people with dementia requires that different forms of expertise should be recognised and used; including the skills and knowledge of care assistants. Successfully engaging with people with dementia and family members and helping them to recognise the dying trajectory requires a supportive integration of emotional and technical expertise. The study strengthens the existing evidence base in this area and will be used with a related set of studies (on the views of other stakeholders and observations and interviews conducted in four services) to develop an evidence-based intervention.
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Affiliation(s)
- Richard Philip Lee
- Institute of Health & Society, Newcastle University, Newcastle-upon-Tyne, United Kingdom
- * E-mail:
| | - Claire Bamford
- Institute of Health & Society, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Marie Poole
- Institute of Health & Society, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Emma McLellan
- Institute of Health & Society, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Catherine Exley
- Faculty of Health & Life Sciences, Northumbria University, Newcastle-upon-Tyne, United Kingdom
| | - Louise Robinson
- Institute of Health & Society, Newcastle University, Newcastle-upon-Tyne, United Kingdom
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Bolton L, Loveard T, Brander P. Carer experiences of inpatient hospice care for people with dementia, delirium and related cognitive impairment. Int J Palliat Nurs 2017; 22:396-403. [PMID: 27568779 DOI: 10.12968/ijpn.2016.22.8.396] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM This study aimed to explore carer experiences of inpatient unit (IPU) hospice care for people with dementia, delirium and related cognitive impairment, following implementation of the Te Kete Marie (TKM) initiative aimed at improving care for this patient group. METHODS Semi-structured interviews were undertaken with 10 carers of people affected by these conditions to ascertain their experiences of the care provided during the IPU stay. RESULTS Analysis of interviews found carer experience could be described by three underlying themes: staff attunement, environmental support, and discharge preparedness, which contributed to a central theme of carer confidence. CONCLUSION The findings suggest that carer confidence is enhanced by: staff awareness and response to individual patient needs, interests and preferences, as well as carer requirements for information and consultation; an environment that engenders experience of comfort, safety, flexibility, privacy and outdoor connection; carer preparedness for patients who subsequently transition home or to alternative residential care.
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Affiliation(s)
- Leanne Bolton
- Registered Nurse, Mary Potter Hospice, Wellington, New Zealand
| | - Tanya Loveard
- Occupational Therapist, Mary Potter Hospice, Wellington, New Zealand
| | - Penny Brander
- Health Researcher, Mary Potter Hospice, Wellington, New Zealand
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31
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Herron R, Rosenberg M, Skinner M. The dynamics of voluntarism in rural dementia care. Health Place 2016; 41:34-41. [DOI: 10.1016/j.healthplace.2016.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 06/22/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
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Iliffe S, Davies N, Manthorpe J, Crome P, Ahmedzai SH, Vernooij-Dassen M, Engels Y. Improving palliative care in selected settings in England using quality indicators: a realist evaluation. BMC Palliat Care 2016; 15:69. [PMID: 27484414 PMCID: PMC4970274 DOI: 10.1186/s12904-016-0144-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 07/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a gap between readily available evidence of best practice and its use in everyday palliative care. The IMPACT study evaluated the potential of facilitated use of Quality Indicators as tools to improve palliative care in different settings in England. METHODS 1) Modelling palliative care services and selecting a set of Quality Indicators to form the core of an intervention, 2) Case studies of intervention using the Quality Indicator set supported by an expert in service change in selected settings (general practice, community palliative care teams, care homes, hospital wards, in-patient hospices) with a before-and-after evaluation, and 3) realist evaluation of processes and outcomes across settings. Participants in each setting were supported to identify no more than three Quality Indicators to work on over an eight-month period in 2013/2014. RESULTS General practices could not be recruited to the study. Care homes were recruited but not retained. Hospital wards were recruited and retained, and using the Quality Indicator (QI) set achieved some of their desired changes. Hospices and community palliative care teams were able to use the QI set to achieve almost all their desired changes, and develop plans for quality improvements. Improvements included: increasing the utility of electronic medical records, writing a manual for end of life care, establishing working relationships with a hospice; standardising information transfer between settings, holding regular multi-disciplinary team meetings, exploration of family carers' views and experiences; developing referral criteria, and improvement of information transfer at patient discharge to home or to hospital. Realist evaluation suggested that: 1) uptake and use of QIs are determined by organisational orientation towards continuous improvement; 2) the perceived value of a QI package was not powerful enough for GPs and care homes to commit to or sustain involvement; 3) the QI set may have been to narrow in focus, or more specialist than generalist; and 4) the greater the settings' 'top-down' engagement with this change project, the more problematic was its implementation. CONCLUSIONS Whilst use of QIs may facilitate improvements in specialist palliative care services, different QI sets may be needed for generalist care settings.
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Affiliation(s)
- Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Nathan Davies
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, Strand, London, WC2B 6NR, UK
| | - Peter Crome
- Research Department of Primary Care & Population Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Sam H Ahmedzai
- Department of Oncology and Metabolism, School of Medicine and Biomedical Science, The University of Sheffield, Sheffield, S10 2RX, UK
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
| | - Yvonne Engels
- Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, 6500 HB, Nijmegen, The Netherlands
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Sommerbakk R, Haugen DF, Tjora A, Kaasa S, Hjermstad MJ. Barriers to and facilitators for implementing quality improvements in palliative care - results from a qualitative interview study in Norway. BMC Palliat Care 2016; 15:61. [PMID: 27422410 PMCID: PMC4947264 DOI: 10.1186/s12904-016-0132-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 07/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation of quality improvements in palliative care (PC) is challenging, and detailed knowledge about factors that may facilitate or hinder implementation is essential for success. One part of the EU-funded IMPACT project (IMplementation of quality indicators in PAlliative Care sTudy) aiming to increase the knowledge base, was to conduct national studies in PC services. This study aims to identify factors perceived as barriers or facilitators for improving PC in cancer and dementia settings in Norway. METHODS Individual, dual-participant and focus group interviews were conducted with 20 employees working in different health care services in Norway: two hospitals, one nursing home, and two local medical centers. Thematic analysis with a combined inductive and theoretical approach was applied. RESULTS Barriers and facilitators were connected to (1) the innovation (e.g. credibility, advantage, accessibility, attractiveness); (2) the individual professional (e.g. motivation, PC expertise, confidence); (3) the patient (e.g. compliance); (4) the social context (e.g. leadership, culture of change, face-to-face contact); (5) the organizational context (e.g. resources, structures/facilities, expertise); (6) the political and economic context (e.g. policy, legislation, financial arrangements) and (7) the implementation strategy (e.g. educational, meetings, reminders). Four barriers that were particular to PC were identified: the poor general condition of patients in need of PC, symptom assessment tools that were not validated in all patient groups, lack of PC expertise and changes perceived to be at odds with staff's philosophy of care. CONCLUSION When planning an improvement project in PC, services should pay particular attention to factors associated with their chosen implementation strategy. Leaders should also involve staff early in the improvement process, ensure that they have the necessary training in PC and that the change is consistent with the staff's philosophy of care. An important consideration when implementing a symptom assessment tool is whether or not the tool has been validated for the relevant patient group, and to what degree patients need to be involved when using the tool.
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Affiliation(s)
- Ragni Sommerbakk
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway. .,Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Aksel Tjora
- Department of Sociology and Political Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marianne Jensen Hjermstad
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, NTNU, Norwegian University of Science and Technology and St. Olavs Hospital, Trondheim University Hospital, P.O. Box 8905, N-7491, Trondheim, Norway.,Regional Centre for Excellence in Palliative Care, Department of Oncology, Oslo University Hospital, Ullevål, Oslo, Norway
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Høgsnes L, Danielson E, Norbergh KG, Melin-Johansson C. Healthcare professionals' documentation in nursing homes when caring for patients with dementia in end of life - a retrospective records review. J Clin Nurs 2016; 25:1663-73. [DOI: 10.1111/jocn.13184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Linda Høgsnes
- Department of Nursing Science; Mid Sweden University; Östersund Sweden
| | - Ella Danielson
- Department of Nursing Science; Mid Sweden University; Östersund Sweden
| | | | - Christina Melin-Johansson
- Department of Nursing Science; Mid Sweden University; Östersund Sweden
- Institute of Health and Care Sciences; The Salhlgrenska Academy; University of Gothenburg; Gothenburg Sweden
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Abstract
BACKGROUND People with dementia may benefit from palliative care which specifically addresses the needs of patients and families affected by this life-limiting disease. On behalf of the European Association for Palliative Care (EAPC), we recently performed a Delphi study to define domains for palliative care in dementia and to provide recommendations for optimal care. An international panel of experts in palliative care, dementia care or both, achieved consensus on almost all domains and recommendations, but the domain concerning the applicability of palliative care to dementia required revision. METHODS To examine in detail, the opinions of the international panel of 64 experts around the applicability of palliative care, we explored feedback they provided in the Delphi process. To examine which experts found it less important or less applicable, ordinal regression analyses related characteristics of the panelists to ratings of overall importance of the applicability domain, and to agreement with the domain's four recommendations. RESULTS Some experts expressed concerns about bringing up end-of-life issues prematurely and about relabeling dementia care as palliative care. Multivariable analyses with the two outcomes of importance and agreement with applicability indicated that younger or less experienced experts and those whose expertise was predominantly in dementia care found palliative care in dementia less important and less applicable. CONCLUSIONS Benefits of palliative care in dementia are acknowledged by experts worldwide, but there is some controversy around its early introduction. Further studies should weigh concerns expressed around care receiving a "palliative" label versus the benefits of applying palliative care early.
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Mahin-Babaei F, Hilal J, Hughes JC. The basis, ethics and provision of palliative care for dementia: A review. Maturitas 2015; 83:3-8. [PMID: 26421475 DOI: 10.1016/j.maturitas.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
Abstract
Interest in palliative care for people with dementia has been around for over two decades. There are clinical and ethical challenges and practical problems around the implementation of good quality palliative care in dementia. This narrative review of the literature focuses on the rationale or basis for services, some of the ethical issues that arise (particularly to do with artificial nutrition and hydration) and on the provision and implementation of services. We focus on the most recent literature. The rationale for palliative care for people with dementia is based on research and on an identified need for better clinical care. But the research largely demonstrates a paucity of good quality evidence, albeit particular interventions (and non-interventions) can be justified in certain circumstances. Numerous specific clinical challenges in end-of-life care for people with dementia are ethical in nature. We focus on literature around artificial nutrition and hydration and conclude that good communication, attention to the evidence and keeping the well-being of the person with dementia firmly in mind will guide ethical decision-making. Numerous challenges surround the provision of palliative care for people with dementia. Palliative care in dementia has been given definition, but can still be contested. Different professionals provide services in different locations. More research and education are required. No single service can provide palliative care for people with dementia.
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Affiliation(s)
- Fariba Mahin-Babaei
- Northumbria Healthcare NHS Foundation Trust, Psychiatry of Old Age Service, Ash Court, North Tyneside General Hospital, North Shields, Tyne and Wear NE29 8NH, UK.
| | - Jamal Hilal
- Northumberland, Tyne and Wear NHS Foundation Trust, St George's Hospital, Morpeth, Northumberland NE61 2NU, UK.
| | - Julian C Hughes
- Northumbria Healthcare NHS Foundation Trust, Psychiatry of Old Age Service and Policy, Ethics and Life Sciences (PEALS) Research Centre, Newcastle University, 4th Floor, Claremont Bridge, Newcastle upon Tyne NE1 7RU, UK.
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Goodman C, Froggatt K, Amador S, Mathie E, Mayrhofer A. End of life care interventions for people with dementia in care homes: addressing uncertainty within a framework for service delivery and evaluation. BMC Palliat Care 2015; 14:42. [PMID: 26383081 PMCID: PMC4574222 DOI: 10.1186/s12904-015-0040-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 09/07/2015] [Indexed: 11/16/2022] Open
Abstract
Background There has been an increase in research on improving end of life (EoL) care for older people with dementia in care homes. Findings consistently demonstrate improvements in practitioner confidence and knowledge, but comparisons are either with usual care or not made. This paper draws on findings from three studies to develop a framework for understanding the essential dimensions of end of life care delivery in long-term care settings for people with dementia. Methods The data from three studies on EoL care in care homes: (i) EVIDEM EoL, (ii) EPOCH, and (iii) TTT EoL were used to inform the development of the framework. All used mixed method designs and two had an intervention designed to improve how care home staff provided end of life care. The EVIDEM EoL and EPOCH studies tracked the care of older people in care homes over a period of 12 months. The TTT study collected resource use data of care home residents for three months, and surveyed decedents' notes for ten months, Results Across the three studies, 29 care homes, 528 residents, 205 care home staff, and 44 visiting health care professionals participated. Analysis of showed that end of life interventions for people with dementia were characterised by uncertainty in three key areas; what treatment is the 'right' treatment, who should do what and when, and in which setting EoL care should be delivered and by whom? These uncertainties are conceptualised as Treatment uncertainty, Relational uncertainty and Service uncertainty. This paper proposes an emergent framework to inform the development and evaluation of EoL care interventions in care homes. Conclusion For people with dementia living and dying in care homes, EoL interventions need to provide strategies that can accommodate or "hold" the inevitable and often unresolvable uncertainties of providing and receiving care in these settings.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care University of Hertfordshire, Hatfield, AL10 9AB, UK.
| | - Katherine Froggatt
- International Observatory on End of Life Care University of Lancaster, Lancaster, UK.
| | - Sarah Amador
- Marie Curie Palliative Care Research Department University College London, London, UK.
| | - Elspeth Mathie
- Centre for Research in Primary and Community Care University of Hertfordshire, Hatfield, UK.
| | - Andrea Mayrhofer
- Centre for Research in Primary and Community Care University of Hertfordshire, Hatfield, UK.
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Davies N, Manthorpe J, Sampson EL, Iliffe S. After the Liverpool Care Pathway--development of heuristics to guide end of life care for people with dementia: protocol of the ALCP study. BMJ Open 2015; 5:e008832. [PMID: 26338688 PMCID: PMC4563245 DOI: 10.1136/bmjopen-2015-008832] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION End of life care guidance for people with dementia is lacking and this has been made more problematic in England with the removal of one of the main end of life care guidelines which offered some structure, the Liverpool Care Pathway. This guidance gap may be eased with the development of heuristics (rules of thumb) which offer a fast and frugal form of decision-making. OBJECTIVE To develop a toolkit of heuristics (rules of thumb) for practitioners to use when caring for people with dementia at the end of life. METHOD AND ANALYSIS A mixed-method study using a co-design approach to develop heuristics in three phases. In phase 1, we will conduct at least six focus groups with family carers, health and social care practitioners from both hospital and community care services, using the 'think-aloud' method to understand decision-making processes and to develop a set of heuristics. The focus group topic guide will be developed from the findings of a previous study of 46 interviews of family carers about quality end-of-life care for people with dementia and a review of the literature. A multidisciplinary development team of health and social care practitioners will synthesise the findings from the focus groups to devise and refine a toolkit of heuristics. Phase 2 will test the use of heuristics in practice in five sites: one general practice, one community nursing team, one hospital ward and two palliative care teams working in the community. Phase 3 will evaluate and further refine the toolkit of heuristics through group interviews, online questionnaires and semistructured interviews. ETHICS AND DISSEMINATION This study has received ethical approval from a local NHS research ethics committee (Rec ref: 15/LO/0156). The findings of this study will be presented in peer-reviewed publications and national and international conferences.
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Affiliation(s)
- N Davies
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - J Manthorpe
- Social Care Workforce Research Unit, Kings College London, London, UK
| | - E L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, London, UK
| | - S Iliffe
- Research Department of Primary Care & Population Health, UCL, London, UK
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Lee RP, Bamford C, Exley C, Robinson L. Expert views on the factors enabling good end of life care for people with dementia: a qualitative study. BMC Palliat Care 2015. [PMID: 26208849 PMCID: PMC4514950 DOI: 10.1186/s12904-015-0028-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Dementia, of all long term illnesses, accounts for the greatest chronic disease burden, and the number of people with age-related diseases like dementia is predicted to double by 2040. People with advanced dementia experience similar symptoms to those dying with cancer yet professional carers find prognostication difficult and struggle to meet palliative care needs, with physical symptoms undetected and untreated. While elements of good practice in this area have been identified in theory, the factors which enable such good practice to be implemented in real world practice need to be better understood. The aim of this study was to determine expert views on the key factors influencing good practice in end of life care for people with dementia. Methods Semi-structured telephone and face-to-face interviews with topic guide, verbatim transcription and thematic analysis. Interviews were conducted with experts in dementia care and/or palliative care in England (n = 30). Results Four key factors influencing good practice in end of life care for people with dementia were identified from the expert interviews: leadership and management of care, integrating clinical expertise, continuity of care, and use of guidelines. Conclusions The relationships between the four key factors are important. Leadership and management of care have implications for the successful implementation of guidelines, while the appropriate and timely use of clinical expertise could prevent hospitalisation and ensure continuity of care. A lack of integration across health and social care can undermine continuity of care. Further work is needed to understand how existing guidelines and tools contribute to good practice. Disclaimer This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (Grant Reference Number RP-PG-0611-20005). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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Affiliation(s)
- Richard Philip Lee
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX, UK.
| | - Claire Bamford
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX, UK.
| | - Catherine Exley
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX, UK.
| | - Louise Robinson
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle-upon-Tyne, NE2 4AX, UK.
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Physician-assisted suicide and/or euthanasia: Pragmatic implications for palliative care [corrected]. Palliat Support Care 2015; 13:1399-409. [PMID: 25670161 DOI: 10.1017/s1478951515000176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues--and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community. METHOD We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized. RESULTS We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered. SIGNIFICANCE OF RESULTS Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.
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Samson T, Shvartzman P. Contradictions and dialectics in the palliative dialogue: enhancing the palliative dialogue by dialectical principles. J Pain Symptom Manage 2014; 48:992-7. [PMID: 24780179 DOI: 10.1016/j.jpainsymman.2014.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 12/29/2013] [Accepted: 01/08/2014] [Indexed: 10/25/2022]
Abstract
The application of required communication skills in the palliative dialogue necessitates a significant transition from the paternalistic medical approach to the holistic psychosocial approach that focuses on the patient and views the individual as a whole entity. Understanding the evolution of a therapeutic relationship in terms of entrance into the relationship, development, maintenance, and leave taking as well as the adoption of dialectical ideas gives palliative caregivers flexibility in the dialogue with patients and families. Accepting the principles of dialectics, in which the existence of contradictions is seen as an inherent part of a reality that is undergoing constant change, gives the caregiver the flexibility to interpret dichotomic thoughts and emotions as a dialectic failure and, in accordance, to move toward a synthesis of the ideas of living and dying. This approach provides caregivers the means to promote the palliative dialogue, implement varied communication skills to clarify the patient's goals, and implement a therapeutic plan to realize them.
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Affiliation(s)
- Tali Samson
- Department of Family Medicine, Pain and Palliative Care Unit, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Maccabi Health Services-Negev District, Beer-Sheva, Israel
| | - Pesach Shvartzman
- Department of Family Medicine, Pain and Palliative Care Unit, Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Pain and Palliative Care Unit, Clalit Health Services - Southern District, Beer-Sheva, Israel.
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Improving the organization of palliative care: identification of barriers and facilitators in five European countries. Implement Sci 2014; 9:130. [PMID: 25686479 PMCID: PMC4203898 DOI: 10.1186/s13012-014-0130-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/19/2014] [Indexed: 11/11/2022] Open
Abstract
Background Interventions to improve palliative care encounter challenges beyond the usual implementation problems because of palliative care’s complex and changing character. In this study, we explored barriers and facilitators faced by health-care professionals in five European countries (England, Germany, Italy, Norway and the Netherlands) with regard to improving the organization of their palliative care service. Methods Semi-structured individual and focus group interviews were conducted with purposefully selected health-care professionals. The constant comparative method was used to analyse the data. Results Professionals working in hospitals, hospices, nursing homes and primary care facilities who provide palliative care to adult patients were interviewed (n =40) or participated in ten focus group interviews (n =59). Barriers and facilitators were inductively grouped into 16 categories and arranged into five themes: innovation, individual professional level, group dynamics, organizational context and local political-economic context. Although the barriers and facilitators identified differed in scope, context, strength and provenance, they were shared by professionals from different European countries. Conclusion This study identified barriers and facilitators to organizational change in palliative care. Some of these barriers and facilitators were experienced by professionals in almost all countries and are therefore prerequisites to change. Understanding the barriers to and facilitators of change will help tailor organizational improvements to the needs of individuals and organizations. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0130-z) contains supplementary material, which is available to authorized users.
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Davies N, Maio L, Rait G, Iliffe S. Quality end-of-life care for dementia: What have family carers told us so far? A narrative synthesis. Palliat Med 2014; 28:919-930. [PMID: 24625567 PMCID: PMC4232347 DOI: 10.1177/0269216314526766] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND People with dementia do not always receive good quality end-of-life care, with undertreated pain, aggressive medical interventions and limited access to hospice care being common. Family carers often provide the majority of informal care for people with dementia, therefore may be best placed to comment on quality of care. AIM We explored what quality end-of-life care for dementia is from the perspective of family carers. DESIGN A review of qualitative evidence taking a systematic approach using a narrative synthesis with tabulation, textual description of studies and thematic analysis as tools, following the guidelines from the Economic and Social Research Council. DATA SOURCES Keywords and subject headings were searched in MEDLINE, EMBASE, CINAHL, SCIE and PsycINFO for studies from 1990 in April 2012 and updated in May 2013. Reference lists were checked and citation searches undertaken. RESULTS Eight studies were included. There was an overarching theme of 'A family's belief of death and their choice of treatment'. Three further themes were then identified to explain family carers' beliefs: the relationship with professionals as a core component of care quality; emotional and commitment pressures of caring and finally, family carers' ability to think about death and dying. CONCLUSION It is difficult to define what constitutes high-quality end-of-life care for people with dementia from the perspective of family carers. Their views expressed in the literature appear to demonstrate more variation of preference of care and treatment and their uncertainty of this.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Laura Maio
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College London, London, UK
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Davies N, Maio L, Vedavanam K, Manthorpe J, Vernooij-Dassen M, Iliffe S. Barriers to the provision of high-quality palliative care for people with dementia in England: a qualitative study of professionals' experiences. HEALTH & SOCIAL CARE IN THE COMMUNITY 2014; 22:386-394. [PMID: 24372976 PMCID: PMC4265301 DOI: 10.1111/hsc.12094] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2013] [Indexed: 06/03/2023]
Abstract
Approaches to palliative care that were originally developed for people with cancer are now being adopted for people with dementia, as a response to many reports of poor-quality care for people with dementia at the end of life. This study explored perceived barriers to the delivery of high-quality palliative care for people with dementia using semi-structured interviews. Recordings were transcribed verbatim and analysed using thematic analysis with an inductive approach and a coding strategy. To improve the trustworthiness of the analysis, independent reading and coding of the transcripts were undertaken, followed by discussions among the four researchers to reach agreement and consensus of the themes. Two group interviews (n = 7 and n = 6), 16 individual interviews and five interviews of pairs of professionals were conducted in 2011/2012 with participants from backgrounds in palliative care, dementia services, palliative care research and policy making. Four themes were identified as barriers to providing high-quality palliative care for people with dementia: (i) ambivalence towards the systematisation of palliative care; (ii) disconnection between services; (iii) different assumptions about training needs; and (iv) negotiation of risk. Understanding these barriers to providing high-quality palliative care for people with dementia could help in the development of a dementia-specific palliative care pathway.
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Affiliation(s)
- Nathan Davies
- Research Department of Primary Care and Population Health, University College LondonLondon, UK
| | - Laura Maio
- Research Department of Primary Care and Population Health, University College LondonLondon, UK
| | - Krish Vedavanam
- Research Department of Primary Care and Population Health, University College LondonLondon, UK
- Central and North West NHS London Foundation TrustLondon, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College LondonLondon, UK
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical CentreNijmegen, The Netherlands
| | - Steve Iliffe
- Research Department of Primary Care and Population Health, University College LondonLondon, UK
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