Palliative care from the perspective of cancer physicians: a qualitative semistructured interviews study

Palliative care: a foreign language? Nurses' perspectives on palliative care in a French comprehensive cancer centre

BACKGROUND

Integrated patient-centred palliative care for cancer patients is widely advocated internationally, but promoting it often proves difficult. The literature suggests that one key factor is physicians' perspectives of palliative care (PC). Nurses' views, however, from their pivotal stance within the healthcare team between patients and physicians, have been less well researched. This study explores French nurses' perspectives on PC, how their view frames their role, and how they experience PC implementation. Nurses' discourse is then explored as a reflection of their experience.

METHODS

Semi-structured interviews were audio-recorded of 21 registered nurses, purposively sampled, in a French comprehensive cancer centre. Reflexive thematic analysis was applied by a team including a patients' rights representative (a PC carer and applied linguist), the quality manager, and three PC physicians. Considerations of speech emphasis and style completed the analysis.

RESULTS

Analysis generated three themes. Nurses perceive PC as a complex and continuous journey, passing through phases to the end of life. It revolves around patients' physical and psychological well-being, timeliness, patient communication and empowerment. This perception frames their caring role as members of the healthcare team, based on necessary knowledge, training, and working conditions allowing them to fulfil their mission. Consequently, they experience PC implementation as either a virtuous or a vicious circle and suggest ways to improve the latter. Analysis of nurses' discourse enhances the meaningfulness of the thematic analysis, reflecting that the more difficult the care context, the more in-depth the description and the more evaluative and emphatic the words chosen.

CONCLUSIONS

These French nurses see their holistic view of PC as diverging from that of physicians, keeping them (painfully) from fulfilling their caregiving role. While the nurses are able to "speak PC" with patients, they see it as a foreign concept/language for physicians (and management), resulting in a sometimes vicious circle of care. Physicians' and management's openness to hearing nurses' views would be a first step towards patient and professional well-being. As the nurses suggest, a palliative approach and communication skills can be learned, and institutions can commit to rethinking priorities, policies, and resources. PC can become a shared language.

Investigating the Relationship between Fear of Failure and the Delivery of End-of-Life Care: A Questionnaire Study

OBJECTIVE

To investigate whether fear of failure (FOF) influences a clinician's perception of how confident and comfortable they are in their delivery of end-of-life (EOL) care.

METHODS

Cross-sectional questionnaire study with recruitment of physicians and nurses across two large NHS hospital trusts in the UK and national UK professional networks. A total of 104 physicians and 101 specialist nurses across 20 hospital specialities provided data that were analysed using a two-step hierarchical regression.

RESULTS

The study validated the PFAI measure for use in medical contexts. Number of EOL conversations, gender, and role were shown to impact confidence and comfortableness with EOL care. Four FOF subscales did show a significant relationship with perceived delivery of EOL care.

CONCLUSION

Aspects of FOF can be shown to negatively impact the clinician experience of delivering EOL care.

CLINICAL IMPLICATIONS

Further study should explore how FOF develops, populations that are more susceptible, sustaining factors, and its impact on clinical care. Techniques developed to manage FOF in other populations can now be investigated in a medical population.

Physician emotional experience of communication and decision making with end-of-life patients: qualitative studies systematic review

OBJECTIVE

To explore the emotional experience of physicians in acute settings when encountering end-of-life conversations and decision making.

METHOD

Thematic synthesis of qualitative studies. Medline, PsychInfo, PubMed, BNI and CIAHL were searched from 1985 to 2021 for studies published in English. Data extraction was informed by a framework created for assessing methodological quality by Polanin, Pigott, Espelage and Grotpeter (2019) and adapted by Draper et al. (2019).

RESULTS

Of 8429 papers identified, 17 were selected for review. Two themes containing 10 subthemes described the emotional and psychological factors impacting the experience of end-of-life care, namely: a tension between desire and ability to communicate end-of-life news, and a conflict of hiding versus revealing self across several practical and emotional contexts.

CONCLUSION

Medical training is only a small factor in how well a person copes with end-of-life care and may sometimes feed negative appraisals . Lack of support from senior colleagues, fear of criticism and a sense of perceived failure were linked to lower self-efficacy in end-of-life care. Beyond learning practical skills, physicians benefit from understanding the psychological factors impacting their experience and in building self-efficacy, and observing senior colleagues effectively process strong and difficult emotions.

PRACTICAL IMPLICATIONS

Promoting personal reflection and sharing of the experiences encountered in end-of-life care, especially modelled from senior colleagues, may contribute to improvements in competence and reduce the impact of heroism, feelings of failure and avoidance in practice.