Death preparedness: a concept analysis

Death preparedness interventions for patients with advanced cancer: A systematic review

Objective

This study aims to synthesize and critically evaluate the current evidence on interventions aimed at enhancing death preparedness among patients with advanced cancer.

Methods

A comprehensive search of PubMed, Embase, Cochrane Library, CINAHL, ProQuest, and Web of Science was conducted to identify relevant studies. The review followed Systematic Review and Meta-Analysis Preferred Reporting Items (PRISMA) guidelines, with a structured assessment of study quality and intervention outcomes.

Results

Nine studies involving a total of 876 patients with advanced cancer met the inclusion criteria. Interventions demonstrated significant improvements in overall death preparedness, with additional benefits observed in psychological well-being and functional status. Most interventions incorporated death education, psychological support, and meaning-centered psychotherapy.

Conclusions

Interventions appear to be effective in enhancing death preparedness among patients with advanced cancer. Future research should focus on refining intervention components, clearly defining outcome measures, and aligning strategies with individualized patient needs and goals.

Systematic review registration

PROSPERO CRD420250652562.

The Experience of Reflexive Hospice Care for Patients With Advanced Cancer: A Qualitative Study

BACKGROUND

Hospice care for patients with advanced cancer mainly takes the family members and healthcare professionals as the main body and the patients as the object. There is a lack of relevant research on reflexive hospice care that considers patients as subjects.

AIM

To explore the experience of reflexive hospice care for patients with advanced cancer.

DESIGN

An empirical phenomenological approach to research was conducted.

METHODS

Data were collected using face-to-face semi-structured interviews between April 3, 2024 and May 27, 2024 in the oncology wards of two comprehensive hospitals. Purposive sampling was used to recruit 18 patients with advanced cancer receiving hospice care. Colaizzi's phenomenological analysis method was used to analyse the data. We followed the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Four themes were identified as being relevant to the experience of reflexive hospice care for patients with advanced cancer: the absence of prior awareness, reconciling with self and others, care and concern for others, and pursuing the meaning of life.

CONCLUSION

This study provides new insights into hospice care for patients with advanced cancer. It emphasises the importance of patients' participation as subjects in hospice care. In reflexive hospice care, patients can actively participate and express their care for others and their understanding of life, thus gaining more respect and care in the end-of-life stage. Therefore, placing patients as the subjects of hospice care and fully respecting and listening to their wishes and needs is one of the most important ways to promote the development of hospice care quality.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

A Model of Death Preparedness in Patients With Advanced Cancer: A Grounded Theory Study

BACKGROUND

Death preparedness in patients with advanced cancer is an important prerequisite for improving the quality of death. However, there are insufficient studies on death preparedness in patients with advanced cancer, and the level of death preparedness needs to be further improved.

AIM

To develop a model of death preparedness in patients with advanced cancer.

METHODS

A qualitative approach with grounded theory was used. Data were collected between February 2024 and July 2024 in the oncology wards of the two general hospitals in Wuhan. We recruited 12 patients, 11 family members, 16 nurses and 4 doctors for semistructured interviews. Data analysis included open coding, axial coding and selective coding. The study is reported using the COREQ checklist.

RESULTS

Death preparedness in patients with advanced cancer is a spiralling process whose core components include death awareness, emotional response, hospice programme and reflexive care, and multiple personal, interpersonal and social factors influence it.

CONCLUSION

A model of death preparedness in advanced cancer patients was constructed through rooted theory, revealing its formation and change process. This model deepens the understanding of death preparedness and helps healthcare providers identify patients' preparedness status in advance to provide more targeted support and care. This personalised care enhances patients' quality of life and reduces the psychological burden on them and their families, achieving more comprehensive and humanised end-of-life care.

IMPACT

To better understand patients' death preparedness, healthcare providers should focus on patients' cognitive, emotional, behavioural and social needs in the process of death preparation from a multifactorial perspective, and provide targeted support and assistance. No Patient or Public Contributions were included in this paper.

Measuring double awareness in patients with advanced cancer: A preliminary scale development study

BACKGROUND

Individuals with advanced cancer face the challenge of living meaningfully while also preparing for end of life. The ability to sustain this duality, called "double awareness," may reflect optimal psychological adaptation, but no psychometric scale exists to measure this construct.

OBJECTIVES

The purpose of this study was to develop a novel scale to measure double awareness in patients living with advanced cancer.

METHODS

Guided by best practices for scale development, this study addresses the first three of nine steps in instrument development, including domain clarification and item generation, establishment of content validity of the items, and pre-testing of the items with patients.

RESULTS

Instrument development resulted in a 41-item measure with two dimensions titled "life engagement" and "death contemplation." Items retained in the measure displayed face validity and were found to be both acceptable by patients and relevant to their lived experience.

SIGNIFICANCE OF RESULTS

The results of this scale development study will allow for full validation of the measure and future use in clinical and research settings. This novel measure of double awareness will have clinical utility and relevance in a variety of settings where patients with advanced cancer are treated.

Death Unpreparedness Due to the COVID-19 Pandemic: A Concept Analysis

The COVID-19 pandemic imposed changes upon the capacity of healthcare systems, with significant repercussions on healthcare provision, particularly at end-of-life. This study aims to analyze the concept map of death unpreparedness due to the COVID-19 pandemic, capturing the relationships among the attributes, antecedents, consequences, and empirical indicators. Walker and Avant's method was used to guide an analysis of this concept. A literature search was performed systematically, between May 2022 and August 2023, using the following electronic databases on the Elton Bryson Stephens Company (EBSCO) host platform: Medical Literature Analysis and Retrieval System Online (Medline), Psychological Information Database (PsycINFO), Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Cochrane Library, and Nursing and Allied Health Collection. Thirty-four articles were retrieved. The unexpected and unpredictable impositions associated with inexperience and unskillfulness in dealing with COVID-19 configured challenges for healthcare professionals, family/caregivers, and even the dying person. Nine key attributes emerged in three main domains: (1) Individual: (a) disease-related conditions, (b) separation distress, and (c) scarcity of death and grief literacy; (2) Relational: (a) Dying alone, (b) poor communication, and (c) existential issues; and (3) Contextual: (a) disrupted collective mourning and grieving, (b) disrupted compassionate care and, (c) pandemic social stigma. This study contributed a full definition of death unpreparedness in a global pandemic scenario such as COVID-19. In this sense, feeling unprepared or unready for death brought new challenges to the bioecological resources of those affected. It is essential to embrace strategies capable of providing emotional and spiritual support in the dying process and to respect patient wishes. The lessons learned from COVID-19 should be applied to events with a comparable impact to minimize their consequences.

Experiences of engaging a death doula: qualitative interviews with bereaved family members

Background

There has been an emerging trend of adopting a death doula, a non-medical advocate and guide for people at the end of life and their families. While there has been growing empirical research regarding the work of death doulas, no studies have been undertaken with the families who have engaged them.

Objectives

To understand the experiences of families who used a death doula in terms of what they did for the patient and family; to understand the benefits and drawbacks of using a death doula; and to use family insight to determine cultural shifts towards death and dying, and what the death doula phenomenon tells us around our attitudes towards death and dying.

Methods

We recruited and interviewed 10 bereaved family members to learn about their experiences using a death doula. This qualitative research took an interpretive phenomenological approach, and thematic analysis was used to analyse the data.

Results

The most valuable attribute the families gained from death doulas was an increase in death literacy resulting in personal empowerment. Empowerment enabled positive end-of-life experiences for the family and personalised deaths for the patient. A novel finding was that the connections and knowledge shared between the death doula and family had a resonant effect, resulting in families being more comfortable with death and keen to share their knowledge with others. Therefore, family engagement of a death doula led to an increase in community awareness around death and dying.

Conclusion

Family members' experience with a death doula was overwhelmingly positive, empowering them practically and emotionally to deliver the best end-of-life care. Empathy and sharing of knowledge by death doulas were valued by families and resulted in an increase in death literacy which provided families with opportunities to 'pay it forward'. Furthermore, the relationships formed between doulas and families have the potential for a lasting, resonant effect.

Factors associated with cancer patients' distinct death-preparedness states

BACKGROUND/OBJECTIVE

Facilitating death preparedness is important for improving cancer patients' quality of death and dying. We aimed to identify factors associated with the four death-preparedness states (no-preparedness, cognitive-only, emotional-only, and sufficient-preparedness) focusing on modifiable factors.

METHODS

In this cohort study, we identified factors associated with 314 Taiwanese cancer patients' death-preparedness states from time-invariant socio-demographics and lagged time-varying modifiable variables, including disease burden, physician prognostic disclosure, patient-family communication on end-of-life (EOL) issues, and perceived social support using hierarchical generalized linear modeling.

RESULTS

Patients who were male, older, without financial hardship to make ends meet, and suffered lower symptom distress were more likely to be in the emotional-only and sufficient-preparedness states than the no-death-preparedness-state. Younger age (adjusted odds ratio [95% confidence interval] = 0.95 [0.91, 0.99] per year increase in age) and greater functional dependency (1.05 [1.00, 1.11]) were associated with being in the cognitive-only state. Physician prognostic disclosure increased the likelihood of being in the cognitive-only (51.51 [14.01, 189.36]) and sufficient-preparedness (47.42 [10.93, 205.79]) states, whereas higher patient-family communication on EOL issues reduced likelihood for the emotional-only state (0.38 [0.21, 0.69]). Higher perceived social support reduced the likelihood of cognitive-only (0.94 [0.91, 0.98]) but increased the chance of emotional-only (1.09 [1.05, 1.14]) state membership.

CONCLUSIONS

Death-preparedness states are associated with patients' socio-demographics, disease burden, physician prognostic disclosure, patient-family communication on EOL issues, and perceived social support. Providing accurate prognostic disclosure, adequately managing symptom distress, supporting those with higher functional dependence, promoting empathetic patient-family communication on EOL issues, and enhancing perceived social support may facilitate death preparedness.

Buen morir en la persona mayor:

El buen morir es un fenómeno que se construye desde múltiples perspectivas de los actores involucrados en la atención del adulto mayor. El objetivo de este trabajo es realizar una revisión temática con análisis cualitativo del contenido 50 artículos relacionados con el buen morir en el adulto mayor publicados en los últimos 10 años. Se encontró que el buen morir carece de una definición universal y está configurada por elementos que varían según el actor involucrado, variables sociodemográficas y aspectos culturales. Visibilizar los elementos más relevantes de lo que configura el buen morir permite ampliar su comprensión, con el objetivo de mejorar la atención en el fin de vida del adulto mayor. Palabras clave: Anciano, muerte, morir, cuidados paliativos, final de vida

Effects of Occupational Stress, Self-Efficacy and Mental Health During the Pandemic on Hospital Sanitation Workers in Malaysia

COVID-19 rapidly spread across the world, constituting a public health disaster unlike any other experienced in decades. The impact exerted on workplaces and their employees was dramatic, and an immense burden fell on healthcare provision globally. Along with "front-line" healthcare staff, sanitation workers at hospitals also had to cope with additional workloads, making them vulnerable to psychological trauma and affecting their quality of life at establishments. This study investigated how the factors of occupational stress, self-efficacy (belief in the capacity to carry out a task well) and mental health altered the WRQoL (Work-Related Quality of Life) of employees carrying out sanitation duties at hospitals in Malaysia. To this end, a survey translated into the Malay language was conducted among 449 such workers during a so-called "recovery movement control order", i.e. quarantine and control measures pertaining to an outbreak of Coronavirus disease. Research involved co-variance-based structural equation modeling, performed in IBM-AMOS-26 software, in order to discern the causal relationship of the aforementioned factors on WRQoL. Results revealed a high level of occupational stress, diminished self-efficacy and poor mental health among the employees surveyed. Such stress directly impacted the WRQoL of the second factor alongside an indirect effect on that of the third, i.e. anxiety stemming from potentially catching the virus and the experience of having to disinfect facilities for treating patients, undertake cleaning duties, and move corpses.

Associations of surrogates' death-preparedness states with decisional conflict and heightened decisional regret over cancer patients' last 6 months of life

OBJECTIVE

Preparing family surrogates for patient death and end-of-life (EOL) decision making may reduce surrogate decisional conflict and regret. Preparedness for patient death involves cognitive and emotional preparedness. We assessed the associations of surrogates' death-preparedness states (that integrate both cognitive and emotional preparedness for patient death) with surrogates' decisional conflict and regret.

METHODS

Associations of 173 surrogates' death-preparedness states (no, cognitive-only, emotional-only, and sufficient preparedness states) with decisional conflict (measured by the Decision Conflict Scale) and heightened decisional regret (Decision Regret Scale scores >25) were evaluated using hierarchical linear modeling and hierarchical generalized linear modeling, respectively, during a longitudinal observational study at a medical center over cancer patients' last 6 months.

RESULTS

Surrogates reported high decisional conflict (mean [standard deviation] = 41.48 [6.05]), and 52.7% of assessments exceeded the threshold for heightened decisional regret. Surrogates in the cognitive-only preparedness state reported a significantly higher level of decisional conflict (β = 3.010 [95% CI = 1.124, 4.896]) than those in the sufficient preparedness state. Surrogates in the no (adjusted odds ratio [AOR] [95% CI] = 0.293 [0.113, 0.733]) and emotional-only (AOR [95% CI] = 0.359 [0.149, 0.866]) preparedness states were less likely to suffer heightened decisional regret than those in the sufficient preparedness state.

CONCLUSIONS

Surrogates' decisional conflict and heightened decisional regret are associated with their death-preparedness states. Improving emotional preparedness for the patient's death among surrogates in the cognitive-only preparedness state and meeting the specific needs of those in the no, emotional-only, and sufficient preparedness states are actionable high-quality EOL-care interventions that may lessen decisional conflict and decisional regret.

Sufficient Death Preparedness Correlates to Better Mental Health, Quality of Life, and EOL Care

CONTEXT

Patients can prepare for end of life and their forthcoming death to enhance the quality of dying.

OBJECTIVES

We aimed to longitudinally evaluate the never-before-examined associations of cancer patients' death-preparedness states by conjoint cognitive prognostic awareness and emotional preparedness for death with psychological distress, quality of life (QOL), and end-of-life care received.

METHODS

In this cohort study, we simultaneously evaluated associations of four previously identified death-preparedness states (no-death-preparedness, cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) with anxiety symptoms, depressive symptoms, and QOL over 383 cancer patients' last six months and end-of-life care received in the last month using multivariate hierarchical linear modeling and logistic regression modeling, respectively. Minimal clinically important differences (MCIDs) have been established for anxiety- (1.3-1.8) and depressive- (1.5-1.7) symptom subscales (0-21 Likert scales).

RESULTS

Patients in the no-death-preparedness and cognitive-death-preparedness-only states reported increases in anxiety symptoms and depressive symptoms that exceed the MCIDs, and a decline in QOL from those in the sufficient-death-preparedness state. Patients in the emotional-death-preparedness-only state were more (OR [95% CI]=2.38 [1.14, 4.97]) and less (OR [95% CI]=0.38 [0.15, 0.94]) likely to receive chemotherapy/immunotherapy and hospice care, respectively, than those in the sufficient-death-preparedness state. Death-preparedness states were not associated with life-sustaining treatments received in the last month.

CONCLUSION

Conjoint cognitive and emotional preparedness for death is associated with cancer patients' lower psychological distress, better QOL, reduced anti-cancer therapy, and increased hospice-care utilization. Facilitating accurate prognostic awareness and emotional preparedness for death is justified when consistent with patient circumstances and preferences.

Describing Death Acceptance Among Thai Buddhists With Cancer

INTRODUCTION

Death acceptance (DA) is perceived in culturally specific ways. The purposes of this study were to describe DA among Thai Buddhists with cancer and to compare DA differences in demographic data.

METHODOLOGY

This research was a secondary data analysis. The participants were 363 Thai Buddhists with cancer, recruited using multistage sampling method. Data were collected using the Buddhist Death Acceptance Scale, reliability coefficient. .82. Data were analyzed using T-Tests and Two-Way ANOVA.

RESULTS

The participants had high levels of DA. Age and stage of cancer had main effects on DA.

DISCUSSION

This study highlighted the significant demographic differences with regard to DA levels among Thai Buddhists with cancer. Interventions include determining the patient's DA level, or offering patients and their families advance care plans. Nurses can then explore DA with patients, particularly those with life-limiting illnesses to ease their patients' lives and foster a good death.

Practical and emotional preparation for death: A mixed methods study investigating experiences of family carers of people with dementia

Background

When family carers are more prepared for the end of the life of a person they care for, they report improved bereavement outcomes. Few studies have explored how carers prepare for the death of a person with dementia. We aimed to explore how carers for people with all stages of dementia experience preparing for end of life care and death.

Methods

This was a mixed methods cross-sectional study. Family carers of people with dementia (n = 150) completed a structured interview with validated scales, alongside questions about death preparedness and advance decisions. A sub-sample (n = 16) completed qualitative interviews exploring their experiences of planning for end of life. We fitted logistic regression models to explore associations with preparedness, and thematically analysed qualitative data.

Results

We addressed practical and emotional preparation separately for 143 participants. Fifty seven percent of participants were very practically prepared for death, while only 29% were very emotionally prepared. Male carers were more likely than female carers to report being very emotionally and practically prepared. Higher engagement with healthcare professionals was associated with feeling very practically prepared; although we found that formal discussions of end of life care issues with healthcare professionals did not impact carers’ feelings of preparation. Higher levels of dementia severity and carer depression were associated with feeling very emotionally prepared. Three qualitative themes related to practical and emotional preparation were identified: (1) ambiguity and uncertainty; (2) support from the system; and (3) how death is perceived by the carer.

Conclusions

While most carers felt practically prepared for death, emotional preparation was much lower. Further research is needed to understand how engagement with healthcare professionals or other forms of social or emotional support could help carers, particularly female carers, to emotionally prepare for their relative’s death.

Caregivers' Death-Preparedness States Impact Caregiving Outcomes and Patients' End-of-Life Care

BACKGROUND/OBJECTIVE

Preparing family caregivers, cognitively, emotionally, and behaviorally, for their relative's death is an actionable component of high-quality end-of-life care. We aimed to examine the never-before-examined associations of conjoint cognitive prognostic awareness and emotional preparedness for death with caregiving outcomes and end-of-life care received by cancer patients.

DESIGN/SETTING/PARTICIPANTS/MAIN MEASURES

For this longitudinal study, associations of death-preparedness states (no-death-preparedness, cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) with subjective caregiving burden, depressive symptoms, and quality of life (QOL) and patients' end-of-life care (chemotherapy and/or immunotherapy, cardiopulmonary resuscitation, intensive care unit care, intubation, mechanical ventilation support, vasopressors, nasogastric tube feeding, and hospice care) were evaluated using multivariate hierarchical linear and logistic regression modeling, respectively, for 377 caregivers in cancer patients' last 6 months and 1 month, respectively.

KEY RESULTS

Caregivers in the cognitive-death-preparedness-only state experienced a higher level of subjective caregiving burden than those in the sufficient-death-preparedness state. Caregivers in the no-death-preparedness and cognitive-death-preparedness-only states reported significantly more depressive symptoms and worse QOL than those in the sufficient-death-preparedness state. Cancer patients with caregivers in the sufficient-death-preparedness state were less likely to receive chemotherapy and/or immunotherapy, intubation, mechanical ventilation, and nasogastric tube feeding than patients with caregivers in other death-preparedness states. However, patients' receipt of hospice care was not associated with their caregivers' death-preparedness states.

CONCLUSION

Family caregivers' death-preparedness states were associated with caregiving outcomes and their relative's end-of-life care. Cultivating caregivers' accurate prognostic awareness and improving their emotional preparedness for their relative's death may facilitate more favorable end-of-life-caregiving outcomes and may limit potentially nonbeneficial end-of-life care.

Death Acceptance Process in Thai Buddhist Patients With Life-Limiting Cancer: A Grounded Theory

Cancer patients with life-limiting illnesses have varied levels of death acceptance pervarious scales. Nevertheless, the process of developing death acceptance in patients with life-limiting cancer remains unclear. This study explores the death acceptance process among patients with life-limiting cancer. We used grounded theory methodology. Data were collected through in-depth interviews of 13 patients with cancer in a palliative care setting, and researchers completed field notes. Data were analyzed using constant and comparative methods. Thai Buddhist patients with cancer in palliative care process death acceptance through three dynamic phases: engaging suffering, being open-minded about death, and adhering to Buddhist practices for increasing death consciousness. The death acceptance process described in this study could serve as a guideline to support death acceptance in Thai Buddhist patients with cancer, and other patients with cancer in palliative care, to improve peaceful life and attain good death.

The effects of confronting one's own end of life on older individuals and those with a life-threatening disease: A systematic literature review

BACKGROUND

Awareness of the impending end of one's life can pose profound existential challenges, thereby impairing well-being. Confronting one's own end of life may be an approach to meet the psychological needs and consequently enhance overall well-being. Different approaches of confrontation have been evaluated positively using measures of psychosocial comfort. To date, there exists no systematic overview on the different ways of confrontation (e.g. psychosocial or individual coping approaches).

AIM

To synthesize the existing knowledge on the effects of different approaches of confronting one's own end of life on older individuals and those with a life-threatening disease.

DESIGN

A systematic review of quantitative, qualitative, and mixed-methods full research reports was conducted. The retrieved studies were screened and appraised for methodological quality by two independent reviewers based on MMAT and CASP. The findings were synthesized narratively using the meta-summary technique by Sandelowski and Barroso.

DATA SOURCES

Medline, PsycINFO, and Web of Science were searched from inception to 12/2020.

RESULTS

N = 49 studies reported on different approaches of confronting one's own end of life, including psychosocial interventions, meaning-enhancing approaches, educational programs, and learning from lived experiences. The results suggest a clear trend toward beneficial effects on psychosocial comfort (e.g. anxiety, sense of meaning, well-being).

CONCLUSION

Low-threshold opportunities of confrontation have the potential to improve well-being and should be emphasized in practical implementation. The results can serve as a comprehensive basis for future research aiming to investigate the determinants of psychosocial comfort for people nearing the end of life.

Distinct Death-Preparedness States by Combining Cognitive and Emotional Preparedness for Death and Their Evolution for Family Caregivers of Terminally Ill Cancer Patients Over Their Last 6 Months of Life

CONTEXT

To identify caregivers' death-preparedness states by combining cognitive and emotional preparedness for their loved one's death as well as their evolution over cancer patients' last 6 months, which have never been explored.

METHODS

Death-preparedness states and their evolution were examined by hidden Markov modeling among 393 caregivers of cancer patients.

RESULTS

Four death-preparedness states were identified: no death preparedness, cognitive death preparedness only, emotional death preparedness only, and sufficient death preparedness. Caregivers in the no-death-preparedness state had neither accurate cognitive prognostic awareness (PA) nor adequate emotional preparedness for death. Caregivers in the sufficient-death-preparedness state reported accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness-only states, caregivers were accurately aware of the patient's prognosis and adequately emotionally prepared for his/her forthcoming death only, respectively. Prevalence of the sufficient-death-preparedness state fluctuated within a narrow range (40.8%-43.2%) over the patient's last six months. Proportions of caregivers decreased in the emotional-death-preparedness-only (19.5%-6.5%) and no-death-preparedness (21.0%-8.2%) states, whereas prevalence of the cognitive-death-preparedness-only state increased substantially (16.3%-44.4%) to become the most prevalent state as death approached.

CONCLUSION

Caregivers of cancer patients heterogeneously experienced combined cognitive and emotional preparedness for death. About 40% of caregivers consistently had sufficient death preparedness over their loved one's dying process. Evaluating these different aspects of death preparedness could be an important approach in high-quality end-of-life care by not only cultivating caregivers' cognitive PA, but also facilitating their emotional preparedness for the patient's death, thus helping caregivers prepare well for their loved one's forthcoming death.

Course of Changes in Emotional Preparedness for Death and Its Associations With Caregiving Outcomes for Family Caregivers of Terminally Ill Cancer Patients Over Their Last Year of Life

BACKGROUND

Preparing family caregivers for a patient's death is an integral component of quality end-of-life care, but temporal changes in emotional preparedness for death and its associations with caregivers' psychological well-being or quality of life (QOL) while providing end-of-life caregiving are under-researched. Our study was conducted to fill this gap.

METHODS

For this prospective, longitudinal study, the course of changes in adequate emotional preparedness for death and its associations with severe depressive symptoms and QOL were examined on 309 consecutive caregivers of terminally ill cancer patients by univariate and multivariate generalized estimating equation analyses, respectively.

RESULTS

Prevalence of adequate emotional preparedness for death was 57.2%, 61.3%, 54.4%, and 46.0% at 181-365, 91-180, 31-90, and 1-30 days before the patient's death, respectively, without significant changes as the patient's death approached. Adequate emotional preparedness for death was associated with caregivers' lower likelihood of severe depressive symptoms (adjusted odds ratio [95% CI]: 0.23 [0.16, 0.32], P < 0.001) but with their better QOL (adjusted β [95% CI]: 7.65 [6.38, 8.92], P < 0.001) in the patient's last year.

CONCLUSIONS

Without active, effective clinical interventions to promote caregivers' emotional preparedness for death, they cannot automatically become more prepared for the patient's death over time. Adequate emotional preparedness for the patient's death benefits caregivers by its associations with a lower likelihood of depressive symptoms and better QOL. Supportive programs for caregivers of terminally ill cancer patients should focus on not only enhancing caregiving skills but also cultivating emotional preparedness for their relative's death to promote their psychological well-being and QOL.

Development and Validation of the Readiness for End-of-Life Conversations (REOLC) Scale

Background: Engaging in end-of-life care considerations is beneficial when the time is right. The purpose of this study is to provide a valid instrument to assess peoples readiness for end-of-life conversations before they are initiated. Materials and Methods: A community sample was recruited in study one for exploratory factor analysis of a 13-item questionnaire. In study two, psychometric properties were analyzed with structural equation modeling in a population affected by cancer. Convergent and discriminant validity were assessed with questionnaires measuring distress, depression, anxiety, fear of progression, and distress of death and dying. Results: In study one (N = 349) exploratory factor analysis resulted in three subscales readiness (α = 0.84), communication (α = 0.76), and values (α = 0.56) with a possible common factor (α = 0.84) for a community sample. In study two (N = 84) the three-factor solution with 13 items was not supported for cancer patients. Factor structure was adapted to 12 items with one common factor readiness (α = 0.87). Model fit was good: χ²(50) = 59.18, p>0.05 (Satorra-Bentler-correction = 1.27), with χ²/df = 1.184, rRMSEA = 0.053 (90%-CI[0.000;0.100]), and rSRMR = 0.072. Convergent validity was supported by moderate correlations to trait gratitude, ratings of readiness to provide a living will or talk with family about the end of life. Divergent validity was supported by no or small correlation with distress, depression, general and death anxiety and fear of progression, respectively. Conclusions: Results support usage of the REOLC Scale in different settings with adapted factor structure. The questionnaire is interpreted as valid and reliable instrument to assess objective readiness for end-of-life conversations.

Family Caregivers' Emotional Preparedness for Death is Distinct from Their Cognitive Prognostic Awareness for Cancer Patients

Background: Cognitive prognostic awareness (PA) and emotional preparedness for a loved one's death are distinct but related phenomena. However, the distinction between these two concepts has not been studied in family caregivers. Objective: To examine whether these two concepts are distinct by comparing their evolution and predictors over cancer patients' last year. Methods: Agreement between emotional preparedness for death and cognitive PA was longitudinally evaluated for 309 family caregivers by percentages and kappa coefficients. Predictors of the two outcomes were evaluated by multivariate logistic regression models with the generalized estimating equation. Results: Agreement between family caregivers' emotional preparedness for death and cognitive PA decreased slightly (54.73%-43.64%) from 181-365 to 1-30 days before the patient's death, with kappa values (95% confidence interval) from -0.060 (-0.123 to 0.003) to 0.050 (-0.074 to 0.174), indicating poor agreement. Participants were more likely to report adequate emotional preparedness for death if they had financial sufficiency, more contact/communication with the patient, lower caregiving burden, and stronger perceived social support. Family caregivers were more likely to have accurate PA if they were 56-65 years old, the patient's adult child, and had more contact/communication with the patient and greater subjective caregiving burden. Conclusions/Implications: Family caregivers' emotional preparedness for death and cognitive PA were distinct, as supported by their poor agreement, lack of reciprocal associations, and two different sets of predictors. Health care professionals should facilitate family caregivers' accurate PA and cultivate their emotional preparedness for death by enhancing patient-family contact/communication and easing their caregiving burden to improve quality of end-of-life care.

The Adaptation of the Buddhist Death Acceptance Scale for Vietnamese Persons with Cancer

PURPOSE

This study reports on selected psychometric properties of the adapted Buddhist Death Acceptance Scale (BDAS) for Vietnamese persons with cancer.

METHODS

The original 13-item BDAS was developed based on Buddhist perspectives toward death and life and was translated from Thai into Vietnamese. Item content checking with five Vietnamese local experts suggested three items of the original BDAS were irrelevant in Vietnamese culture and hence should be excluded. Psychometric properties of the 10-item BDAS Vietnamese version were tested using a convenience sample of 193 Vietnamese Buddhists with cancer.

RESULTS

The internal consistency coefficient of the scale was found to be 0.73. Exploratory factor analysis showed that the 10 items of the BDAS Vietnamese version constituted 2 factors, explaining 51.1% of the variance of death acceptance. The first factor was "acceptance of natural process of death" and the second was "preparing for death." Both factors reflected explicitly Buddhist viewpoints toward death acceptance and were consistent with the original Thai BDAS. However, although similar factors were found, some items in the Vietnamese BDAS did not load to same factors as in the Thai BDAS.

CONCLUSIONS

The BDAS Vietnamese version provides an initial suitable measurement for death acceptance among Vietnamese Buddhists. Its availability will enable cross-cultural research to investigate death acceptance among Buddhist patients with cancer in Vietnam. However, the differences in item loadings between the Thai and Vietnamese scales suggest that further conceptual and empirical works to refine the measurement are needed.

Conjoint cognitive and emotional death-preparedness states and their changes within cancer patients' last 6 months

BACKGROUND/OBJECTIVE

Cognitive prognostic awareness (PA) and emotional preparedness for death are distinct but related concepts that have rarely been investigated conjointly and without considering the dynamic nature of death preparedness. To fill this gap, this secondary-analysis study identified distinct patterns/states of death preparedness and their changes within cancer patients' last 6 months.

METHODS

Distinct death-preparedness states, determined by conjoint cognitive PA and emotional preparedness for death, as well as their changes between consecutive times were identified and estimated, respectively, by latent transition modeling with hidden Markov modeling among 383 cancer patients within their last 6 months.

RESULTS

Four death-preparedness states (prevalence) were initially identified: no death preparedness (17.1%), cognitive death preparedness only (23.3%), emotional death preparedness only (39.9%), and sufficient death preparedness (19.7%). Patients in the no-death-preparedness state had neither accurate PA nor adequate emotional preparedness for death. The sufficient-death-preparedness state was characterized by both accurate PA and adequate emotional preparedness for death. In the cognitive- and emotional-death-preparedness-only states, patients were accurately aware of their prognosis and adequately emotionally prepared for their forthcoming death only, respectively. As death approached, state prevalence fluctuated within a narrow range for the no- and sufficient-death-preparedness states, whereas prevalence of cognitive- and emotional-death-preparedness-only states increased and decreased substantially, respectively.

CONCLUSION

Cancer patients heterogeneously experienced conjoint cognitive PA and emotional preparedness for death, and prevalence of death-preparedness states changed substantially as death approached. Effective interventions are warranted to cultivate cognitive PA and facilitate emotional death-preparedness to improve end-of-life-care quality, thereby helping patients achieve a good death.

Hospice care self-efficacy among clinical medical staff working in the coronavirus disease 2019 (COVID-19) isolation wards of designated hospitals: a cross-sectional study

BACKGROUND

The COVID-19 pandemic has caused more than 462,417 deaths worldwide. A large number of patients with severe COVID-19 face death in hospital. Hospice care is truly a philosophy of care that delivers patient-centred care to the terminally ill and their families. Hospice care could provide many benefits for patients, families, and for hospice caregivers. The aim of this study is to investigate hospice care self-efficacy and identify its predictors among Chinese clinical medical staff in COVID-19 isolation wards of designated hospitals.

METHODS

A cross-sectional design was used. The Hospice Care Self-Efficacy, Self-Competence in Death Work Scale, Positive Aspects of Caregiving, and Simplified Coping Style Questionnaires were administered between February and April 2020. A total of 281 eligible medical staff responded to the questionnaires, with a response rate of ≥78.9%.

RESULTS

The mean score of hospice care self-efficacy was 47.04 (SD = 7.72). Self-efficacy was predicted by self-competence in death work (B = 0.433, P < 0.001), positive aspects of caregiving (B = 0.149, P = 0.027), positive coping (B = 0.219, P < 0.001), giving hospice care to dying or dead patients before fighting against COVID-19 (B = -1.487, P = 0.023), occupational exposure while fighting against COVID-19 (B = -5.244, P = 0.004), holding respect for life and professional sentiment as motivation in fighting against COVID-19 (B = 2.372, P = 0.031), and grade of hospital employment (B = -1.426, P = 0.024). The variables co-explained 58.7% variation of hospice care self-efficacy.

CONCLUSION

Clinical nurses and physicians fighting COVID-19 reported a moderate level of hospice care self-efficacy during this pandemic. Exploring the traditional Chinese philosophy of life to learn from its strengths and make up for its weaknesses and applying it to hospice care may provide a new framework for facing death and dying during the COVID-19 pandemic. Continuous hospice care education to improve self-competence in death work, taking effective measures to mobilize positive psychological resources, and providing safer practice environments to avoid occupational exposure are also essential for the improvement of the hospice care self-efficacy of clinical nurses and physicians. These measures help caregivers deal effectively with death and dying while fighting against the COVID-19 pandemic.

Death acceptance from a Thai Buddhist perspective: A qualitative study

PURPOSE

To have more in-depth understanding of death acceptance among patients with terminal cancer in Thailand.

METHODS

A qualitative descriptive research approach was used to capture the perspectives of patients with terminal cancer about death acceptance. Purposive sampling was used to recruit the participants. A semi-structured interview guide was used during data collection to obtain in-depth interviews with 12 patients diagnosed with terminal cancer. An interpretive descriptive method was used for analyzing data. Analysis of the data for this study was conducted by the analytic team beginning at initial data collection.

RESULTS

The findings of this study revealed six major themes relating to death acceptance: 1) perceiving death as a natural part of life; 2) perceiving that death cannot be controlled; 3) thinking that death can come at any time; 4) letting everything go before dying: finding a calmness; 5) additional Buddhist practices: clean living and making merit; and 6) additional means for attaining a peaceful death and peaceful life before death.

CONCLUSION

Understanding death acceptance is important for nurses providing care for patients with terminal cancer in order to find strategies and support for patients to accept death and live peacefully with their family in the time they have left.

Terminally Ill Cancer Patients' Emotional Preparedness for Death Is Distinct From Their Accurate Prognostic Awareness

CONTEXT

Emotional preparedness for death (hereafter called death preparedness) and prognostic awareness (PA), a distinct but related concept, each contributes to patients' practical, psychological, and interpersonal preparations for death. However, the distinction between these two concepts has never been investigated.

OBJECTIVES

To evaluate the distinction between death preparedness and accurate PA by examining their agreement during cancer patients' last year and the similarity of their predictors.

METHODS

For this secondary analysis of a longitudinal study of death preparedness for 277 patients with cancer, agreement between death preparedness and accurate PA was evaluated by percentages and kappa coefficients, and predictors of the two outcomes were evaluated by multivariate logistic regression models with the generalized estimating equation.

RESULTS

Levels of agreement between reported death preparedness and accurate PA increased slightly (42.44%-52.85%) from 181-365 days to one to 30 days before death, with kappa values from -0.190 (-0.319, -0.061) to -0.006 (-0.106, 0.093), indicating poor agreement. Participants who were male, older, reported financial sufficiency, had fewer distressing symptoms, and perceived higher levels of social support were more likely to report death preparedness. Participants who were female, had greater than high-school educational attainment, and endured higher levels of functional dependence were more likely to report accurate PA.

CONCLUSION

The distinction between death preparedness and accurate PA was supported by their poor agreement, lack of reciprocal associations, and two different sets of predictors. Health care professionals should not only cultivate cancer patients' accurate PA but also facilitate emotional preparation for death to achieve a good death and improve end-of-life care quality.

Courses of Change in Good Emotional Preparedness for Death and Accurate Prognostic Awareness and Their Associations With Psychological Distress and Quality of Life in Terminally Ill Cancer Patients' Last Year of Life

CONTEXT

Emotional preparedness for death is a distinct but related concept to prognostic awareness (PA). Both allow patients to prepare psychologically and interpersonally for death, but they have primarily been examined in cross-sectional studies.

OBJECTIVES

To 1) explore the courses of change in good emotional preparedness for death and accurate PA and 2) evaluate their associations with severe anxiety symptoms, severe depressive symptoms, and quality of life in cancer patients' last year.

METHODS

For this prospective, longitudinal study, we consecutively recruited 277 terminally ill cancer patients. Aims 1 and 2 were examined by univariate and multivariate generalized estimating equation analyses, respectively.

RESULTS

The prevalence of good emotional preparedness for death was 54.43%-65.85% in the last year, with a significant decrease only 91-180 vs. 181-365 days before death (odds ratio [95% CI] = 0.67 [0.47, 0.97]). Good emotional preparedness for death was associated with a lower likelihood of severe anxiety symptoms (adjusted odds ratio [95% CI] = 0.47 [0.27, 0.79]) and severe depressive symptoms (0.61 [0.39, 0.95]), but not with quality of life (β [95% CI] = 0.49 [-2.13, 3.11]). However, accurate PA improved substantially (55.12%-70.73%) as death approached and accurate PA was positively associated with severe depressive symptoms (2.63 [1.63, 4.25]).

CONCLUSION

Good emotional preparedness for death and accurate PA remained largely stable and improved substantially, respectively, in cancer patients' last year. Both measures were significantly associated with psychological distress. Health care professionals should not only cultivate accurate PA but also promote cancer patients' emotional preparedness for death, which may improve their psychological well-being.

Palliative care for patients with motor neurone disease and their bereaved carers: a qualitative study

Background

Internationally, it is widely accepted that holistic care is as an integral part of the care for people with motor neurone disease (MND), and their informal carers. However the optimal role of generalist and specialist palliative care, and how it integrates with specialist neurology services, is not fully established. Using a qualitative approach we sought to examine end of life care for people with MND in Northern Ireland, and the role of specialist and generalist palliative care.

Methods

Qualitative study involving a convenience sample of 13 bereaved carers recruited using the Northern Ireland MND Register. Data collection consisted of semi-structured interviews with the bereaved carers of patients who had died 3–24 months previously with a diagnosis of MND. Data were analysed using thematic analysis.

Results

Findings illuminated variations in relation to the levels of holistic care provided to this cohort of patients. Unmanaged respiratory and psychological symptoms caused perceived distress amongst patients. Participants’ experiences additionally highlighted reluctance amongst patients with MND to engage with services such as specialist palliative care. Conversely, for those who received input from specialist palliative care services carers portrayed these services to be of great benefit to the patient.

Conclusions

Patients with MND in Northern Ireland may have many unmet holistic care needs. Key areas that require particular focus in terms of service development include neuromuscular respiratory physiotherapy and psychological services for patients. Future research must explore an optimal model of holistic care delivery for patients with MND and how this can be effectively integrated to best meet this patient cohorts palliative care needs.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0423-8) contains supplementary material, which is available to authorized users.

Prepared for end-of-life care: a concept analysis

BACKGROUND

Recent international documents have highlighted the importance of preparing the nursing workforce for end of life care. However, these documents do not make clear what prepared in the context of end-of-life care actually means. Searching the literature failed to retrieve any papers defining prepared in this context.

AIM

A concept analysis, using Walker and Avant's model, was conducted to help address this gap in the knowledge base.

RESULTS

From this analysis many attributes and antecedents were synthesised. These include that a prepared nurse would be confident to: assess the dying patient, communicate with empathy, identify and manage symptoms, recognise and deal with death and dying, understand the holistic elements of dying, be comfortable with the effects of loss and bereavement on patients and self, and be self-competent.

CONCLUSIONS

From this analysis, a clearer idea of what is needed to prepare nurses for end-of-life care is offered and suggestions for future research are made.

Preparedness for Death: How Caregivers of Elders With Dementia Define and Perceive its Value

Purpose

The purpose of this study is to ascertain how bereaved caregivers of a family member who died from a dementia-related diagnosis (a) define preparedness and (b) perceive its value.

Design and Methods

Purposive criterion sampling was employed to identify 30 bereaved caregivers of family members aged 65 and older who died with a dementia-related diagnosis. In-depth, qualitative interviews were conducted over a 12-month period, and qualitative content analysis was used to analyze the data.

Results

Only one third (n = 10) of caregivers interviewed were prepared for the death, and the majority who were prepared were enrolled in hospice. Five primary themes revealed ways that caregivers define various domains of preparedness: (i) accepting reality; (ii) knowing death is near; (iii) getting your "house in order"; (iv) saying "what you need to say"; and (v) giving "permission" to die. The majority (87%) believed that it is important for caregivers to be prepared, and the value of preparedness was exemplified in five domains reflecting the benefits of being prepared.

Implications

The results support further attention to the development and testing of interventions to address the unmet needs of caregivers of family members with dementia to help prepare them for the death in a variety of contexts.

Cancer patient perspectives regarding preparedness for end-of-life care: A qualitative study

PURPOSE

The extent to which patients feel prepared for end-of-life (EOL) may be associated with important clinical outcomes. Despite growing interest in the concept of "preparedness," however, there is insufficient information about what cancer patients actually need to feel prepared. Such information is foundational for patient-centered care, theory-building, and instrument development.

DESIGN

This qualitative study examined patient perspectives regarding preparedness for EOL care.

PARTICIPANTS AND METHODS

In-depth interviews were conducted with patients with advanced malignancies and limited life expectancies. Participants were drawn from a large academic cancer center and had a diverse range of malignancies. Thematic text analysis was used to analyze the data.

FINDINGS

Six overarching themes emerged. These included readiness to manage concerns about: (1) EOL planning (e.g., goals of care, location of care); (2) interactions with healthcare providers (e.g., communication, symptom control); (3) interactions with family/friends (e.g., perceived burden, support); (4) emotional well-being (e.g., existential distress, fulfillment); (5) spiritual well-being (e.g., spiritual comfort, congregational support); and (6) financial well-being (e.g., medical expenses, estate planning).

CONCLUSIONS

Findings highlight areas that patients themselves regard as critical for a sense of preparedness for EOL care. Participants emphasized broader concerns than those previously construed as facets of patient preparedness, and these domains offer modifiable targets for intervention.

Community perspectives of end-of-life preparedness

While death is a universal human experience, the process of planning for death can be difficult and may be avoided altogether. To understand community perspectives of end-of-life preparedness, we undertook a multimethod study exploring the experiences of 25 community members and 10 stakeholders engaged in end-of-life planning. In addition, card sorting activities and focused discussions with 97 older adults were undertaken to highlight perspectives and needs. Data were analyzed using descriptive statistics and qualitative description. Overall, the participants perceived many benefits to being end-of-life prepared, however, few community members had engaged in formal planning. Key barriers include concerns about the accessibility and accuracy of information, discomfort when engaging in end-of-life conversations, and perceptions about the cost associated with engaging in formal legal or financial preparations. Areas for further research include the need for studies that capture the cultural dimensions of end-of-life planning and explores the implementation and evaluation of community-based interventions to improve preparedness.

Nursing Support of Home Hospice Caregivers on the Day of Patient Death

PURPOSE/OBJECTIVES

To describe nurse-caregiver communication on the day of patient death.
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DESIGN

A descriptive secondary analysis of 44 audio-recorded home hospice nursing visits on day of death.
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SETTING

Nine hospices in Utah, Oregon, and Massachusetts.
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SAMPLE

42 caregiver-patient dyads, 27 hospice nurses.
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METHODS

Transcripts of audio recordings were coded for supportive nursing communication and relative time spent in physical, psychosocial, and spiritual discussion.
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MAIN RESEARCH VARIABLES

Tangible, emotional, informational, esteem, and networking supportive communication; nurses' self-reported communication effectiveness; caregiver religious affiliation.
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FINDINGS

Nurses reported that their communication skills were less effective when discussing difficult topics as compared to their overall communication effectiveness. Eleven patients died before the nursing visit, 3 died during the visit, and 30 died post-visit. Nurses primarily engaged in discussions facilitating caregiver emotional, tangible, and informational support. More informational support was observed when patient death occurred during the nursing visit. Time spent in general conversation showed that physical care conversations predominated (80% of the average overall amount of conversation time), compared to lifestyle/psychosocial discussions (14%) and spiritual discussions (6%). Spiritual discussions were observed in only 7 of 44 hospice visits. Spiritual discussions, although short and infrequent, were significantly longer, on average, for caregivers without a religious affiliation.
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CONCLUSIONS

Nurses support caregivers on the day of patient death using multiple supportive communication strategies. Spiritual discussions are minimal.
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IMPLICATIONS FOR NURSING

Communication skills programs can potentially increase self-reported communication effectiveness. Emerging acute spiritual concerns, particularly for caregivers without a previous religious affiliation, should be anticipated. Spiritual support is included in the hospice model of holistic care.

The experience of palliative care service provision for people with non-malignant respiratory disease and their family carers: An all-Ireland qualitative study

AIM

To explore specialist and generalist palliative care provision for people with non-malignant respiratory disease, in rural and urban areas in the North and Republic of Ireland.

BACKGROUND

Globally, palliative care is recommended as an appropriate healthcare option for people with advanced non-malignant lung disease. Yet, there is limited evidence regarding the integration of palliative care for this client group.

DESIGN

Qualitative study.

METHODS

Convenience sample of 17 bereaved carers and 18 healthcare professionals recruited from two rural and two urban sites on the Island of Ireland. Data were collected throughout 2012 and 2013 through semi-structured interviews with carers of patients with Chronic Obstructive Pulmonary Disease (N = 12), interstitial lung disease (N = 4) or bronchiectasis (N = 1) who had died 3-18 months previously; and four focus groups with healthcare professionals. Data were analysed using a thematic analysis framework.

RESULTS

Carers' interviews yielded three overarching themes: (1) lack of preparedness for death, due to ambiguity regarding disease trajectory; (2) lack of consistency in palliative care delivery, in relation with the receipt of generalist and specialist palliative care; and (3) role ambiguity, related to their caregiving role. Focus groups identified two overarching themes: (1) barriers to appropriate palliative care; and (2) the future direction of palliative care for patient with non-malignant respiratory disease.

CONCLUSION

The uncertain disease trajectory was not only experienced by carers but also healthcare professionals. Although referral to specialist palliative care services was perceived as increasing, the availability and coordination of generalist and specialist palliative care services were fragmented and varied dependent on geographical location.

Health and death literacy and cultural diversity: insights from hospital-employed interpreters

Objectives

001225The aim of this qualitative study is to better understand, through the experiences and insights of hospital interpreters, how people from culturally and linguistic diverse (CALD) communities might respond to advance care planning (ACP) and end-of-life discussions.

Methods

Hospital interpreters from five Melbourne metropolitan health services were recruited for in-depth semi-structured interviews that explored the question, ‘What can be learnt from hospital interpreters about cultural issues related to ACP and end-of-life decision-making?’ Thirty-nine interpreters, representing 22 language groups, were interviewed. Analysis of the transcribed interviews used qualitative description.

Results

Thematic analysis identified three major themes: (1) moral difference; (2) health and death literacy; and (3) diversity within culture.

Conclusion

A value-based approach to ACP is recommended as a way to capture the person’s individual values and beliefs. Health and death literacy have been identified as areas that may be over-estimated; areas that can be addressed and improved, if recognised. Health and death literacy is a particular area that needs to be assessed and addressed as a pre-requisite to ACP discussions.

Death Attitudes Among Middle-Aged Koreans: Role of End-of-Life Care Planning and Death Experiences

The purpose of this study was to examine factors affecting death attitudes among middle-aged Koreans. In addition, the study explored the interaction effect between knowledge about end-of-life care planning and the experience of death of family or friends on death attitudes. The sample was obtained from a national survey with middle-aged adults in South Korea ( n = 2,026). Multivariate regression analysis revealed significant main effects and an interaction effect between knowledge about end-of-life care planning and the experience of death on death attitudes. Greater knowledge of end-of-life care planning was associated with more positive attitudes toward death; however, the effect was stronger for those who had not experienced the death of family or friends. Being older and having greater life satisfaction were also associated with more positive attitudes toward death. This study suggests that end-of-life education can help middle-aged adults embrace the final stage of life and prepare for their own death.

Preparation for the end of life and life completion during late-stage lung cancer: An exploratory analysis

Objective:

Our aim was to explore preparation for the end of life (EoL) and life closure among persons with advanced metastatic lung cancer. Understanding quality of life through the lens of preparation and completion is important since the trajectory of lung cancer can be relatively short, often leading to application of cancer-directed therapies near death without the opportunity for advance planning or palliative care. Clinical research is needed to understand the kinds of distress specific to older adults with advanced lung cancer that are amendable to palliative care interventions.

Method:

We employed an exploratory cross-sectional design to examine psychosocial and existential concerns among a purposive sample (N = 30) of advanced lung cancer patients using the “end-of-life preparation” and “life completion” subscales of the Quality of Life at the End of Life (QUAL–E) questionnaire. Nonparametric methods were employed to analyze preparation, completion, global quality of life (QoL), and the associations among depressive symptoms, preparation, completion, and global QoL.

Results:

Higher scores on life completion were associated with better global QoL, and with items related to transcendence, communicative acts, and interpersonal relationships demonstrating important contributions. The perception of being a future burden on family members was the greatest concern within the preparation domain. Depressive symptoms were not associated with preparation, completion, or global QoL.

Significance of Results:

Psychosocial and existential issues contribute to QoL at the EoL among older adults with late-stage lung cancer during cancer-directed therapy, concurrent care, and hospice. The role of preparation, especially self-perceived burden, merits further research early on in the oncological setting. The preparation and life completion subscales of the QUAL–E are feasible clinical tools for facilitating dyadic communication about sensitive topics in the palliative care setting.

Old age and forgoing treatment: a nationwide mortality follow-back study in the Netherlands

BACKGROUND

The ageing of the population raises the need to study forgoing treatment decisions among older people.

AIM

To describe the incidence and decision-making of forgoing treatment and identify age-related differences.

METHODS

A nationwide study of a stratified sample from the Statistics Netherlands death registry to which all deaths were reported in 2010. All attending physicians of those deaths received a questionnaire about end-of-life decisions. 6600 cases were studied. We examined three age groups: 17-64, 65-79, and 80 and above. Logistic regression analyses were performed to identify age-related differences controlling for other patient characteristics.

RESULTS

Forgoing treatment occurred in 37% of the total population, with a significant increase in the incidence across age. The most common treatments withheld/withdrawn were artificial hydration/nutrition, medication and antibiotics. Age-related differences were found, especially for withholding artificial hydration/nutrition among patients aged 65-79 (OR 2.04), and for withdrawing medication (OR 2.51) and antibiotics (OR 2.10) among the oldest when compared to the youngest patients. The most common reason for making the decision was 'no chance of improvement'. The likelihood of forgoing treatment due to 'loss of dignity' was higher for the oldest (OR 2.32), as well as due to the request/wish of the patient (OR 1.97), when compared to the youngest patients.

CONCLUSIONS

Forgoing treatment occurred in a substantial proportion of older people, and more often than in younger age groups. The avoidance of burdensome treatment solely to prolong life suggests a better acceptance that these patients are nearing death.

Examining family meetings at end of life: The model of practice in a hospice inpatient unit

OBJECTIVE

Our purpose was to rigorously examine the nature of family meetings as conducted in an inpatient hospice care unit in order to generate an inductive theoretical model.

METHOD

In this two-phase project, we first interviewed eight members of the interdisciplinary care team who participated in multiple family meetings each week. Interview questions explored why and how they conducted family meetings. Using an observation template created from these interview data, we subsequently conducted ethnographic observations during family meetings. Using the methods of grounded theory, our findings were synthesized into a theoretical model depicting the structure and process of formal family meetings within this setting.

RESULTS

The core of the family meeting was characterized by cognitive and affective elements aimed at supporting the family and facilitating quality care by clarifying the past, easing the present, and protecting the future. This inductive model was subsequently found to be highly aligned with a sense of coherence, an important influence on coping, and adaptation to the stress of a life-limiting illness.

SIGNIFICANCE OF RESULTS

Provider communication with family members is particularly critical during advanced illness and end-of-life care. The National Consensus Project clinical practice guidelines for quality palliative care list regular family meetings among the recommended practices for excellent communication during end-of-life care, but do not provide specific guidance on how and when to provide such meetings. Our findings provide a theoretical model that can inform the design of a family meeting to address family members' needs for meaningful and contextualized information, validation of their important contributions to care, and preparation for the patient's death.