'No control whatsoever': end-of-life care on a medical teaching unit from the perspective of family members

Facilitating family needs and support at the end of life in hospital: A descriptive study

BACKGROUND

Caring for family members of dying patients is a vital component of end-of-life care, yet family members' needs at the end of life may be unmet.

AIM

To explore hospital clinician assessment and facilitation of family needs and practices to support families at the end of life.

DESIGN

Descriptive study utilising a retrospective medical record audit.

SETTING AND SAMPLE

Undertaken in a large public hospital, the sample included 200 deceased patients from four specialities; general medicine (n = 50), intensive care (n = 50), inpatient palliative care (n = 50) and aged rehabilitation (n = 50). Data were analysed according to age; under 65-years and 65-years or over.

RESULTS

Deceased patients' mean age was 75-years, 60% were Christian and Next-of-Kin were documented in 96% of cases. 79% spoke English, yet interpreters were used in only 6% of cases. Formal family meetings were held in 64% of cases. An assessment of family needs was undertaken in 52% of cases, and more likely for those under 65-years (p = 0.027). Cultural/religious practices were supported/facilitated in only 6% of all cases. Specialist palliative care involvement was more likely for those aged 65-years or over (p = 0.040) and social work involvement more likely for those under 65-years (p = 0.002). Pastoral care and bereavement support was low across the whole sample.

CONCLUSIONS

Prioritising family needs should be core to end-of-life care. Anticipation of death should trigger routine referral to support personnel/services to ensure practice is guided by family needs. More research is needed to evaluate how family needs assessment can inform end-of-life care, supported by policy.

Appropriateness of intensive care treatments near the end of life during the COVID-19 pandemic

The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity.

KEY POINTS

The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted.

EDUCATIONAL AIMS

To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.

Sitting with silence: hospital social work interventions for dying patients and their Families

The recent controversy around the hospital end of life care has highlighted the vulnerability of dying patients and their families. However, little is known about how social workers provide support and intervention around the end of life in the hospital. Eight hospital social workers provided qualitative descriptions of their clinical practice for adult patients and their families. Highlighting a theoretical orientation towards a person-in-environment approach, social workers develop unique interventions to contribute to multidisciplinary care. Findings emphasize the need to prepare social work students and clinicians for the reality of working with end of life issues.

Occupational balance among family members of people in palliative care

Background: Today people can live a long time with a chronic cancer diagnosis, and it affects the entire family. Family members to patients in palliative care often have to leave valued occupations due to lack of time and energy, while new roles are forced upon them, potentially affecting their health.Objective: To explore occupational balance, needs and roles among family members to persons in palliative care.Methods: Six semi-structured interviews were conducted with family members to terminally ill persons enrolled to specialized palliative care. A qualitative content analysis guided the data collection and analysis.Result: An overarching theme Striving for control while being in the disease, and two categories Changing roles and occupations in the family; and Handling emotions in the end of life emerged from the data.Conclusion: The findings suggest that family members could benefit from strategies to maintain valued roles and occupations, and that palliative care provision need to develop new ways to take family members needs into consideration.

The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

BACKGROUND

Standardized protocols have been previously shown to be helpful in managing end-of-life (EOL) care in hospital. The comfort measures order set (CMOS), a standardized framework for assessing imminently dying patients' symptoms and needs, was implemented at a tertiary academic hospital.

OBJECTIVE

We assessed whether there were comparable differences in the care of a dying patient when the CMOS was utilized and when it was not.

METHODS

A retrospective chart review was completed on patients admitted under oncology and general internal medicine, who were referred to the inpatient palliative care team for "EOL care" between February 2015 and March 2016.

RESULTS

Of 83 patients, 56 (67%) received intiation of the CMOS and 27 (33%) did not for EOL care. There was significant involvement of spiritual care with the CMOS (66%), as compared to the group without CMOS (19%), P < .05. The use of CMOS resulted in 1.7 adjustments to symptom management per patient by palliative care, which was significantly less than the number of symptom management adjustments per patient when CMOS was not used (3.3), P < .05. However, initiating CMOS did not result in a signficant difference in patient distress around the time of death ( P = .11). Dyspnea was the most frequently identified symptom causing distress in actively dying patients.

CONCLUSIONS

Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Still Searching: A Meta-Synthesis of a Good Death from the Bereaved Family Member Perspective

The concept of a good death continues to receive attention in end-of-life (EOL) scholarship. We sought to continue this line of inquiry related to a good death by conducting a meta-synthesis of published qualitative research studies that examined a good death from the bereaved family member's perspective. Results of the meta-synthesis included 14 articles with 368 participants. Based on analysis, we present a conceptual model called The Opportunity Model for Presence during the EOL Process. The model is framed in socio-cultural factors, and major themes include EOL process engagement with categories of healthcare participants, communication and practical issues. The second theme, (dis)continuity of care, includes categories of place of care, knowledge of family member dying and moment of death. Both of these themes lead to perceptions of either a good or bad death, which influences the bereavement process. We argue the main contribution of the model is the ability to identify moments throughout the interaction where family members can be present to the EOL process. Recommendations for healthcare participants, including patients, family members and clinical care providers are offered to improve the quality of experience throughout the EOL process and limitations of the study are discussed.

Improving end-of-life care through quality improvement

Although end of life (EoL) care has been identified as an area for quality improvement in hospitals, the quality of care Canadian patients receive at the end of life is not well-evidenced. National statistics indicate that Canadians would prefer to die at home, yet more than 50% die in acute care hospital settings. Busy and often highly specialised acute care units may be perceived as a distressing place of death for both patients and their families. Furthermore, many clinicians are not trained in diagnosing imminent dying, managing symptoms at the end of life or supporting dying patients and their families. As such, to improve the experience of EoL care, a corporate, institution-wide strategy entitled the Quality Dying Initiative was introduced and implemented across a tertiary care academic teaching hospital. A primary focus of this initiative was the implementation of a comprehensive Comfort Measures Strategy. This strategy involved the development of an evidence-based order set, which included elements of symptom assessment and management, patient and family education, and spiritual and emotional support. Staff education and mentoring was also a critical element of the larger Comfort Measures Strategy, as well as an evaluative component.

How to Deal With Relatives of Patients Dying in the Hospital? Qualitative Content Analysis of Relatives' Experiences

CONTEXT

Hospital care and communication tend to be focused on the individual patient, and decision making is typically based on the principle of individual autonomy. It can be questioned whether this approach is adequate when a patient is terminally ill.

OBJECTIVES

Our aim was to explore the involvement and experiences of relatives in the hospital during the patient's last phase of life.

METHODS

This study was embedded in a retrospective questionnaire study on the quality of dying of a consecutive sample of patients who died in a general university hospital in The Netherlands. We performed a secondary qualitative analysis of relatives' comments and answers to open questions. Relatives of 951 deceased adult patients were asked to complete a questionnaire; 451 questionnaires were returned and analyzed for this study.

RESULTS

Relatives expressed a need for 1) comprehensible, timely, and sensitive information and communication, 2) involvement in decision making, 3) acknowledgment of their position, 4) being able to trust health care staff, and 5) rest and privacy. When relatives felt that their role had sufficiently been acknowledged by health care professionals (HCPs), their experiences were more positive.

CONCLUSION

Relatives emphasized their relation with the patient and their involvement in care of the patient dying in the hospital. An approach of HCPs to care based on the concept of individual autonomy seems inadequate. The role of relatives might be better addressed by the concept of relational autonomy, which provides HCPs with opportunities to create a relationship with relatives in care that optimally addresses the needs of patients.

Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: does location matter?

BACKGROUND

Improving end-of-life care is an important international issue. Recently Nova Scotia researchers conducted a mortality follow-back survey to provide a population-based description of care provided to adults during their last 30 days of life as perceived by knowledgeable bereaved family members. Here we describe the relationship between the location where the decedent received the majority of care during their last 30 days and the informant's perception of the extent of unmet need, as defined by multiple domains of patient-focused, family-centred care.

METHOD

Death certificate identified informants (next-of-kin) of eligible adults who died between June 2009 and May 2011, in Nova Scotia, Canada were invited to participate in a telephone interview based on the After-Death Bereaved Family Member Interview. Whether or not the informant expressed unmet need or concerns for six patient-focused, family-centred care domains were assessed in relation to the location where the majority of care occurred during the decedent's last 30 days.

RESULTS

1358 informants took part (25% response rate). Results of 1316 eligible interviews indicated home (39%) was the most common location of care, followed by long-term care (29%), hospital (23%) and hospital-based palliative-care units (9%). Unmet need ranged from 5.6% for dyspnea help to 66% for the emotional and spiritual needs of the family. Although the mean score for overall satisfaction was high (mean = 8.7 in 1-10 scale; SD 1.8), 57% were not completely satisfied. Compared to home, adjusted results indicated greater dissatisfaction with overall care and greater communication concerns in the hospital. Greater unmet need occurred at home for dyspnea. Less overall dissatisfaction and unmet need were expressed about care provided in long-term care facilities and hospital-based palliative-care units.

CONCLUSION

Bereaved informants were generally highly satisfied with the decedent's care during their last 30 days but variations were evident. Overall, no one location stood out as exceptionally different in terms of perceived unmet need within each of the patient-focused, family-centred care domains. Communication in various forms and family emotional and spiritual support were consistently viewed as lacking in all locations and identified as targeted areas for impacting quality care at end of life.

The development and validation of a shorter version of the Canadian Health Care Evaluation Project Questionnaire (CANHELP Lite): a novel tool to measure patient and family satisfaction with end-of-life care

CONTEXT

The recently developed Canadian Health Care Evaluation Project (CANHELP) questionnaire, which can be used to assess both patient and family satisfaction with end-of-life care, takes 40-60 minutes to complete. The length of the interview may limit its uptake and clinical utility; a shorter version would make its use more feasible.

OBJECTIVES

The purpose of this study was to develop and validate a shorter version of the CANHELP questionnaire.

METHODS

Data were collected using a cross-sectional survey of patients with advanced medical diseases and their family members. Participants completed the long version of CANHELP, a global rating of satisfaction with care (GRS), the FAMCARE scale (family members only), and a quality-of-life (QOL) questionnaire. We reduced the items on the long version based on their relationship to the GRS, the frequency of missing data, the distribution of responses, the redundancy of the items, and focus groups with frontline users. With the remaining items, we assessed internal consistency using Cronbach's alpha, and evaluated construct validity by describing the correlation of the new CANHELP Lite with the full version of CANHELP, GRS, FAMCARE, and the QOL questionnaire scores.

RESULTS

A total of 363 patients and 193 family members participated in this study. The patient version was reduced from 37 items to 20 items and the caregiver version was reduced from 38 items to 21 items. Cronbach's alphas ranged from 0.68 to 0.93 for all domains of both the patient and caregiver questionnaires. We observed a high degree of correlation between CANHELP Lite domains and overall scores and the same domains and overall scores for the full version of CANHELP. In addition, we observed moderate to strong correlation between the CANHELP Lite overall satisfaction scores and the GRS questions. There was moderate correlation between the overall family member CANHELP Lite score and overall FAMCARE score (r = 0.45) and this was similar to the correlation between the full version of CANHELP and FAMCARE scores (r = 0.41). CANHELP Lite correlated more strongly with the QOL subscale on health care than the other QOL subscales.

CONCLUSION

The CANHELP Lite questionnaire is a valid and internally consistent instrument to measure satisfaction with end-of-life care.

Quality of end-of-life care for non-cancer patients in a non-acute hospital

AIMS AND OBJECTIVES

Few surveys have been carried out documenting the quality of life for non-cancer patients in general district hospitals reaching the final trajectory towards death. We carried out a survey of 80 patients facing the final stages of their chronic illness as well as their carers and hospital staff.

BACKGROUND

With increasing life expectancy, a large majority of patients are older, where palliative care principles for patients with cancer are equally applicable. Few surveys have been carried out documenting the quality of life for non-cancer patients in general district hospitals reaching the final trajectory towards death in terms of patients' and carers' perspective, compared with the more extensive literature for patients with cancer.

DESIGN

Survey.

METHODS

Assessment tools include symptom check list, geriatric depression scale, Chinese Death Anxiety Inventory and the McGill Quality of Life Questionnaire for patients; SF-12 and the Chinese cost of care index for informal carers; and the Chinese Maslach Bumout and Death Anxiety Inventories for hospital staff.

RESULTS

Lower-limb weakness (92·5%), fatigue (86·2%), oedema (85%), dysphagia (58·2%) and pain (48·8%) were the most common symptoms in this group of patients. The mean Chinese Caregiver Stress Index score was 45·93 (SD 6·45) (maximum score = 80). For staff, the mean SF-12 physical component score was lower than the Hong Kong population average.

CONCLUSION

The findings suggest that there is room for improvement in the quality of end-of-life care. Relevance to clinical practice.  Patients in the final stages of many chronic illnesses have high prevalence of symptoms comparable to those of patients with cancer. Raising awareness and improving training for all health care professionals, formulating guidelines and care pathways and incorporating quality of care as key performance indicators are measures to improve the quality of end-of-life care.

Defining priorities for improving end-of-life care in Canada

BACKGROUND

High-quality end-of-life care should be the right of every Canadian. The objective of this study was to identify aspects of end-of-life care that are high in priority as targets for improvement using feedback elicited from patients and their families.

METHODS

We conducted a multicentre, cross-sectional survey involving patients with advanced, life-limiting illnesses and their family caregivers. We administered the Canadian Health Care Evaluation Project (CANHELP) questionnaire along with a global rating question to measure satisfaction with end-of-life care. We derived the relative importance of individual questions on the CANHELP questionnaire from their association with a global rating of satisfaction, as determined using Pearson correlation coefficients. To determine high-priority issues, we identified questions that had scores indicating high importance and low satisfaction.

RESULTS

We approached 471 patients and 255 family members, of whom 363 patients and 193 family members participated, with response rates of 77% for patients and 76% for families. From the perspective of patients, high-priority areas needing improvement were related to feelings of peace, to assessment and treatment of emotional problems, to physician availability and to satisfaction that the physician took a personal interest in them, communicated clearly and consistently, and listened. From the perspective of family members, similar areas were identified as high in priority, along with the additional areas of timely information about the patient's condition and discussions with the doctor about final location of care and use of end-of-life technology.

INTERPRETATION

End-of-life care in Canada may be improved for patients and their families by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.