A matter of definition--key elements identified in a discourse analysis of definitions of palliative care

'Not a panacea' - Expert perspectives on the concept of resilience and its potential for palliative care

Background

Resilience is an increasingly used term in medicine and subject to various definitions, often not easy to grasp. There are established core concepts for patients receiving palliative care, for example, meaning in life, that have already been researched a lot. Resilience, relative to these concepts, is a new object of research in palliative care, where it has so far been used predominantly with regard to the well-being of teams.

Aim

To explore how experts in palliative care define the concept of resilience and its suitability for patients, significant others, and professionals.

Design

Qualitative study using summarizing content analysis according to Mayring.

Setting/participants

Twenty-one health and social care professionals with expertise caring for persons with life-threatening/limiting illnesses and their relatives were interviewed in three individual interviews and four focus groups. All conversations were recorded, transcribed, coded via MAXQDA, and validated by another researcher.

Results

Resilience has been described as something procedural, dynamic, individual, and flexible. In connection with well-known concepts such as posttraumatic growth or terms from the field of mindfulness, social environment or personal factors have also been linked to resilience. Resources such as spirituality can contribute to resilience, and resilience itself can function as a resource, for example, by contributing to quality of life. An active use of the term in practical work with patients or relatives is rare, but it is used in education or team measures. Limited lifespan can pose a challenge to an active use of the concept of resilience.

Conclusion

Resilience as a very individual approach provides added value to other core concepts of palliative care. Within the palliative context, the normative dimension of resilience must be well reflected. A broader definition of resilience is recommended, leaving room for everyone to find their own form of resilience. The concept of resilience in palliative care includes opportunities as well as risks and should, therefore, be implemented carefully, requiring specific training.

The palliative care experience in Irish nursing homes during the COVID-19 pandemic: a survey of residents, family, and staff

BACKGROUND

Nursing homes and other long-term care services account for a disparate share of COVID-19 cases and casualties worldwide. During COVID-19 there is a distinct need to preserve a holistic view of the wellbeing of residents of nursing homes, be mindful of their rights as citizens, and to be aware of protecting residents from infection. The delivery of health and social care throughout a pandemic must remain person-centred and adhere to a human rights-based approach.

METHODS

This study aimed to capture nursing home residents, their families and staff's perspective of the nursing homes residents experience, approaches of staff and the nursing home environment. An online survey was distributed via stakeholder networks and online platforms across Ireland. This study was performed and reported in line with the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).

RESULTS

25 residents, 42 family members and 51 staff completed the survey (n = 118). Across the domains measured all but one aspect scored above 50% (residents get up and go to bed when they want 41.5%) with the highest score of 89.1% scored for the nursing home is comfortable and well-kept. Results highlight evidence of positive experiences and endeavours to preserve social connections, residents were in a safe place cared for by staff who did their best in a difficult position and who went above and beyond their duty of care. However, some families reported poor communication, no internet connections, not enough phones or tablets, and that staff were busy and unable at times to assist residents who needed help using phones/tablets.

CONCLUSION

This study highlights the importance of human rights and how they ought to inform and shape the advancement of public health advice and policy documents. Overall, nursing home residents, their families and staff reported favourably on the study measures. However, issues pertaining to communication are essential and there is a need to address issues such as the provision of accurate timely information, communication infrastructure and resources, and inconsistencies in communications. Of note is that while healthcare professionals have a duty to uphold the rights of nursing home residents, they themselves have human rights which must also be protected and supported.

The Impact of Qualification and Hospice Education on Staff Attitudes during Palliative Care in Pediatric Oncology Wards-A National Survey

BACKGROUND

Our knowledge about the attitudes of healthcare staff to palliative care in pediatric oncology is scarce. We aimed to assess their perceptions of palliative care in Hungary and find answers to the question of how to provide good palliative care for children.

METHOD

Physicians (n = 30) and nurses (n = 43) working in the field of pediatric oncology (12 of them specialized in hospice care) were interviewed. Palliative care practice (communication, integration of palliative care, professionals' feelings and attitudes, and opportunities for improvement) was assessed by semi-structured interviews evaluated in a mixed quantitative and qualitative way by narrative categorical content analysis and thematic analysis.

RESULTS

All providers displayed high negative emotions, positive evaluations, and used many active verbs. Nurses showed higher levels of denial, more self-references, and were more likely to highlight loss. Physicians emphasized the importance of communication regarding adequate or inadequate palliative care. Hospice specialists showed a higher passive verb rate, a lower self-reference, a lower need for psychological support, and a greater emphasis on teamwork and professional aspects.

CONCLUSION

Our results show that nurses are more emotionally stressed than doctors in palliative care in pediatric oncology. To our knowledge, a study comparing doctors and nurses in this field has yet to be carried out. Our results suggest that pediatric oncological staff can positively evaluate a child's palliative care despite the emotional strain. Regarding hospices, professional practice in palliative care may be a protective factor in reducing emotional distress and achieving professional well-being.

Clinical pharmacist in oncology palliative medicine: drug compliance and patient adherence

OBJECTIVES

Most patients in palliative oncology care are polymorbid and thus treated with multiple drugs. The therapeutic effect and safety of these drugs can be compromised by drug/drug interactions, but also by wider problems such as polypharmacy and compliance. The clinical pharmacist is, therefore, responsible for risk analysis and prevention. Our prospective open label non-randomised clinical study evaluated the importance of a clinical pharmacist in the palliative care team.

METHODS

A total of 250 outpatients were included in the clinical study: 126 women (50.4%) and 124 men (49.6%), with a mean age of 71 years (range 21-94 years; SD 11.9). The patients had the performance status scale 0-3 [Formula: see text]. Clinical examinations were performed on a monthly basis (n=509 check-up visits). The clinical pharmacist prepared an educational chart for all medications used after each visit and evaluated any drug-related problems. Follow-up was 6 months.

RESULTS

This study found a significant association between drug related-problems and polypharmacy (p<0.001). A low risk of drug-rfelated problems was observed during the initial visit, that is, 68 female (27.2%) and 25 male (10.4%) patients. A greater clinical-pharmaceutical risk was observed among the patients taking antihypertensive drugs (p=0.003) and/or beta blockers (p=0.048).

CONCLUSION

This study confirms the essential role of a clinical pharmacist in oncology palliative care. The feedback obtained from the patients showed a notable improvement in their quality of life. Further, this clinical study confirmed the need for a personalised approach in palliative oncology care.

Sipping as a Nutritional Supplement in Ambulatory Palliative Oncology Care: A Pilot Study with Noninvasive Methods

Objective: The implementation of nutritional support is a basic need of patients in palliative oncological care. This pilot study optimized the use of sipping to improve the nutritional status of cancer patients in palliative care. Materials and Method: The pilot study included 63 patients, 61.3 years of age on average (range: 32-82 years of age). The patients were assigned to either group A (no nutritional support n = 39 patients) or group B (sipping as nutritional support n = 24 patients). The patients were evaluated through by noninvasive methods: body weight, waist and arm circumference, and triceps skinfold, bioimpedance analysis, and dynamometry. Quality of life was assessed through modified questionnaires. Results: In contrast with group A, group B did not have a significant weight loss, that is, A: 81.9 ± 15.8-80.5 ± 15.8 kg (P = .028) and B: 73.9 ± 14.9-73 ± 16 kg. Body mass index A: 29 ± 5-28.5 ± 5 kg/m2 (P = .007) and B: 25.3 ± 4.7-25 ± 4.9 kg/m2 (P = .614). Waist circumference A: 93.5 ± 15.1-92.5 ± 14.8 cm (P = .008) and B: 80.1 ± 13.2-80.6 ± 12.3 cm (P = .234). Triceps skinfold A: 12.3 ± 7.2-11 ± 6.7 mm (P = .001) and B: 8.2 ± 6.1-7.9 ± 5.7 mm (P = .207). Fat free mass A: 54.8 ± 11.5-52.8 ± 11.6 kg (P = .018) and B: 54.7 ± 10.9-52.8 ± 11.5 kg (P = .207). Significantly lower dynamometer values were recorded in both groups; A: 25.6 ± 10.4-23.1 ± 10.3 kg (P = .010) and B: 27.4 ± 9.9-24.3 ± 9.1 kg (P = .009). In contrast to group B, the patients in group A showed slight variations in their health status, thus decreasing their scores into the significance limit (P = .072). Conclusion: Our results suggest that providing nutritional support in the form of sipping (∼12 g proteins, 300 kcal) on a daily basis prevents the loss of active tissue mass in palliative oncology patients. Based on these results, we recommend the inclusion of this simple nutritional support to prevent malnutrition in cancer patients in palliative care. The clinical study was registered by the internal ethics committee under the heading of its approval - Institutional Ethics Committee of the Hradec Králové Faculty Hospital, number 201311S2OP.

[Who is afraid of Ockham's razor? : A discourse analysis on resilience in palliative care (2000-2021)]

BACKGROUND

The concept of resilience is becoming increasingly disseminated from material science into various fields of science. It is infiltrating medical fields predominantly via psychology and is also recommended for coping with the special burdens in pain management and palliative care. A precise definition of the term and its operationalization pose problems.

AIM

A critical stocktaking of the use of this term in the discourse of palliative care research.

METHOD

Analytical discourse analysis of a text corpus from palliative medical care publications in the time period from 2000 to 2021, obtained by means of a systematic literature search.

RESULTS

In the research discourse of palliative care, resilience is a topic primarily as a strategy for self-optimization of employees (e.g., burnout prophylaxis with the aim of preserving the workforce). Only rarely does the question of whether it offers potential for patients and their families take center stage, and then more as a catchword than as a concrete concept. The reason is that there is so far no adequate operationalization of the concept of resilience. Furthermore, there is a lack of sufficient justification for the relevance of the concept in patient care of palliative medicine.

CONCLUSION

There is a lack of qualified contributions of palliative research to the metadiscourse about resilience, especially in the context of affected patients. A successful operationalization of the term requires a highly complex multidimensionality of the palliative path of an interdisciplinary approach. There is a lack of ethical standards that prevent an affirmative instrumentalizing application of the term.

Barriers to participation in tourism linked respite care

Successive interventions designed to curb the spread of COVID-19 have all served to exacerbate the demands placed upon informal carers, a population indispensable to health care systems. The need for breaks from caring has never been so pronounced. This paper adopts, and extends, the theory of hierarchical leisure constraints to better understand barriers to tourism respite participation. Lived experiences are collected via story-telling techniques (n = 157) from carers taking trips of one night or more away during times of palliative and end-of-life care. Three cross-cutting constraints are emergent in the data: awareness (knowing); access (doing); and anxiety (feeling). Negotiation strategies are suggested, hierarchical implications questioned and the opportunity to explore a temporal dimension to tourism constraints in future research signalled.

Palliative Care and Physician Assisted Death

In the recent decade quite a few countries and regions legalised physician assisted death. While palliative care is already or becoming the standard end of life care in many countries, the increased availability of physician assisted death coupled with the secularisation of hospice in more settings require – where this has not happened yet – a clear response of palliative care specialists to patients’ requests for physician assisted death. The paper analyses the World Health Organisation’s current description of palliative care with a special focus on its prohibition of hastening death. Some palliative care professionals do not agree with the ban on hastening death, and these professionals’ non-conventional interpretation of palliative care actually seems to meet the wishes of some patients.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team

Background

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care.

Aim

This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task.

Methods

An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Results

Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care.

Implications

This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Healthcare Professionals' Perspective on Palliative Care in Intensive Care Settings: An Interpretive Descriptive Study

There is a growing need to integrate palliative care into intensive care units and to develop appropriate knowledge translation strategies. However, multiple challenges persist in attempts to achieve this objective. In this study, we aimed to explore intensive care professionals' perspectives on providing palliative and end-of-life care within an intensive care context. We used an interpretive description approach and interviewed 36 intensive care professionals at four hospitals in Saudi Arabia. Our findings reflect a discourse about end-of-life care driven by a do-not-resuscitate classification and challenges associated with family involvement in care goals. We provide key insights of importance for the development of strategies for the integration and knowledge translation of palliative care into intensive care contexts.

Rehabilitation interventions for depression symptoms among cancer patients in Palestine: A systematic review

Background

Depression enhances the disease burden in patients with cancer. Psychological interventions and the rehabilitation of depression are required as a part of palliative care for cancer patients to improve their quality of life and mental health.The aim of the study was to review the literature about depression rehabilitation interventions among patients with cancer in Palestine.

Method

The electronic databases used: PubMed, Science Direct, Research Gate, and Google Scholar to search for systematic review articles for the review study.

Results

A total of 23 articles were reviewed, including five from Palestine and five from Arab and Islamic nations. Pharmacological and non-pharmacological interventions used to decrease symptoms of depression and enhance mental health among cancer patients represent the majority of interventions for depression rehabilitation in cancer patients. Interventions for depression rehabilitation among cancer patients in Palestine are only available from the perspective of palliative care, which also involves family education, managing the symptoms of cancer patients, and providing psychological support.

Conclusion

In Palestine, non-pharmacological interventions, such as psychological interventions, are the primary options for treating and recovering from symptoms of depression. The management of symptoms in cancer patients also has a favorable impact on mental health and recovery from depression. In Palestine, there is a need for improvement in palliative care, particularly interventions for depressive symptoms. The main reason Palestinian patients with cancer have such limited treatment and recovery options are because of Israeli occupation.

Cannabis in Palliative Care: A Systematic Review of Current Evidence

CONTEXT

Palliative care aims to improve the quality of life in patients with incurable illness. Medicinal cannabis (MC) has been used in the palliative care setting to address multiple symptoms in patients.

OBJECTIVES

To evaluate the full scope of available literature investigating the effects and potential harms of MC on symptom management and quality of life in palliative care.

METHODS

PubMed, Embase, The Cochrane Library and clinicaltrials.gov were searched for eligible articles, published between 1960 and September 9, 2021. Quality of the evidence was assessed in accordance with Grading of Recommendations, Assessment, Development and Evaluations. Risk of bias was assessed using the RoB 2 tool for randomised controlled trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool for non-randomized trials.

RESULTS

Fifty-two studies (20 randomised; 32 non-randomised) with 4786 participants diagnosed with cancer (n = 4491), dementia (n = 43), AIDS (n = 235), spasticity (n = 16), NORSE syndrome (n = 1) were included. The quality of evidence was 'very low' or 'low' for all studies, and low for only two randomised controlled trials. Positive treatment effects (statistical significance with P < 0.05) were seen for some MC products in pain, nausea and vomiting, appetite, sleep, fatigue, chemosensory perception and paraneoplastic night sweats in patients with cancer, appetite and agitation in patients with dementia and appetite, nausea and vomiting in patients with AIDS. Meta-analysis was unable to be performed due to the wide range of cannabis products used and the heterogeneity of the study outcomes.

CONCLUSION

While positive treatment effects have been reported for some MC products in the palliative care setting, further high quality evidence is needed to support recommendations for its use in clinical practice.

Open banking: A bibliometric analysis-driven definition

"Open banking," as a concept, was initially developed by a UK regulation to foster competition in banking through sharing client data (with their consent) amongst competitors. Today, it is regulated in several most relevant banking jurisdictions. Despite its growing relevance, consensus about the definition of open banking is lacking. This study examines 282 articles on open banking using bibliometric clustering techniques. Moreover, within the 282 articles and applying discourse analysis, we analyze 47 idiosyncratic definitions of open banking to test an integral framework that supports our proposed definition of the concept. Our study contributes to the literature by providing a generalized multidisciplinary definition of open banking. It identifies four main drivers behind the concept: business model change, client data sharing, incorporation of technological companies (fintechs and others), and regulation. These four elements, which should be considered in new regulations in the globalized banking sector, foresee open banking as a critical enabler of a new strategic dynamic in banking.

Physicians' Conceptions of the Dying Patient: Scoping Review and Qualitative Content Analysis of the United Kingdom Medical Literature

Most people in high income countries experience dying while receiving healthcare, yet dying has no clear beginning, and contexts influence how dying is conceptualised. This study investigates how UK physicians conceptualise the dying patient. We employed Scoping Study Methodology to obtain medical literature from 2006-2021, and Qualitative Content Analysis to analyse stated and implied meanings of language used, informed by social-materialism. Our findings indicate physicians do not conceive a dichotomous distinction between dying and not dying, but construct conceptions of the dying patient in subjective ways linked to their practice. We argue that the focus of future research should be on exploring practice-based challenges in the workplace to understanding patient dying. Furthermore, pre-Covid-19 literature related dying to chronic illness, but analysis of literature published since the pandemic generated conceptions of dying from acute illness. Researchers should note the ongoing effects of Covid-19 on societal and medical awareness of dying.

Association between the Development of Hospice and Palliative Care and Government-Funded Research Priority: Taiwan-Based Example

In recent years, hospice and palliative care (HPC) has grown, developed, and changed in response to the humanistic and social needs for supporting those with incurable illnesses. As a relatively new discipline, research is needed in HPC, and the priority setting of research is essential to help direct finite resources to support research. To promote creative research in different fields including HPC, the Taiwan government subsidized institutions to conduct research. In this study, we obtained data from the Government Research Bulletin, an open-source online system containing complete information about government subsidized studies since 1993 to investigate the development of research priority in HPC in Taiwan. In total, 552 studies were recorded during 1993–2021, with a continued upward trend. An association was found between research priority and the promulgation of new HPC regulations. The type of diseases in research extended from cancer to all advanced chronic conditions. The increased diversity in out-of-hospital settings of palliative research was also observed. Numerous studies have focused on education, and the theme gradually shifted from “training and education for healthcare professionals” to “public education”. Here, the results may serve as a basis to understand the commonalities of research and enhance dialog in HPC research.

Family-clinician shared decision making in intensive care units: Cluster randomized trial in China

OBJECTIVE

To investigate if a Family-Clinician Shared Decision-Making (FCSDM) intervention benefits patients, families and intensive care units (ICUs) clinicians.

METHODS

Six ICUs in China were allocated to intervention or usual care. 548 patients with critical illness, 548 family members and 387 ICU clinicians were included into the study. Structured FCSDM family meetings were held in the intervention group. Scales of SSDM, HADS, QoL2 and CSACD were used to assess families' satisfaction and distress, patients' quality of life, and clinicians' collaboration respectively.

RESULTS

Comparing the intervention group with the control group at post-intervention, there were significant differences in the families' satisfaction (P = 0.0001), depression level (P = 0.005), and patients' quality of life (P = 0.0007). The clinicians' mean CSCAD score was more positive in the intervention group than controls (P < 0.05). There was no significant between-group differences on ICU daily medical cost, but the intervention group demonstrated shorter number of days' stay in ICU (P = 0.0004).

CONCLUSION

The FCSDM intervention improved families' satisfaction and depression, shortened patients' duration of ICU stay, and enhanced ICU clinicians' collaboration.

PRACTICE IMPLICATIONS

Further improvement and promotion of the FCSDM model are needed to provide more evidence to this field in China.

Evolution of Oncology and Palliative Nursing in Meeting the Changing Landscape of Cancer Care

Nursing is a vital health profession. In almost all clinical and hospital settings, nurses offer primary palliative care. Nurses are recognized for their strong philosophy of care for a wide spectrum of disorders. No matter the sickness, condition, or clinical situation, palliative care is considered essential in nursing practice. Palliative care nursing is the provision of palliative care services to cancer patients and their families, regardless of whether cancer can be cured or not. A large body of evidence shows that early palliative care nursing integration improves the quality of life and survival of cancer patients. Due to the intricacy of cancer, the landscape of cancer care is shifting. Cancer is a life-threatening disease with a high mortality rate. Oncology nurses' skills and experience are vital in providing specialized patient care and fulfilling the needs of patients and their families. The current study examines the shifting environment of palliative care nursing in oncology. However, new palliative care nursing approaches are required to adapt to the evolving cancer scenario.

An Operational Definition of End-of-Life Healthcare: A Complex and Subjective Construct

Comprehensively defining end-of-life healthcare is a challenge due to the diverse areas of healthcare involved, the various stakeholders, and the range of patient options. This qualitative study examined many areas of end-of-life healthcare including quality, areas for improvement, and healthcare policy in Tennessee, in which the definition of end-of-life healthcare was a focus. Data were collected using semi-structured interviews with 19 participants who included end-of-life healthcare experts and Tennessee legislators. Through this research an operational definition of end-of-life healthcare, encompassing five concepts, was developed. Concepts include: a diagnosis, a timeframe, type of care, location of care, and planning for the future. When considered together, they are the embodiment of what end-of-life healthcare encompasses. Not in a one-fits-all definition, but individually tailored. An understanding of what end-of-life healthcare denotes is essential to maintaining open communication, high quality standards of care, and the protection of patient autonomy.

Making room for life and death at the same time - a qualitative study of health and social care professionals' understanding and use of the concept of paediatric palliative care

BACKGROUND

The concept of pediatric palliative care (PPC) is applied differently within the healthcare system and among healthcare professionals (HCPs). To our knowledge, no studies have investigated how multidisciplinary HCPs understand the concept of PPC and the aim of this study was to explore the concept of PPC from the view of HCP in a paediatric setting.

METHODS

We employed an explorative and descriptive design and conducted four focus groups with a total of 21 HCPs working in hospitals with children in palliative care. The data were analysed using qualitative content analysis.

RESULTS

The data analysis of the concept of pediatric palliative care resulted in two themes. The first theme "A frightening concept that evokes negative emotions," contains categories to explore the meaning, named "An unfamiliar and not meaningful concept, "A concept still associated with death and dying" and "Healthcare professionals' responsibility for introducing and using the concept and, to obtain a common meaning." The second theme was named "A broad and complementary concept," containing the categories "Total care for the child and the family," "Making room for life and death at the same time" and "The meaning of alleviation and palliative care."

CONCLUSIONS

The included HCPs reflected differently around PPC but most of them highlighted quality of life, total care for the child and the child's family and interdisciplinary collaboration as core elements. Attention to and knowledge among HCPs might change the perception about PPC from a frightening concept to one that is accepted by all parties, implemented in practice and used as intended. However, our study reveals that there is still some work to do before PPC is understood and accepted by all those involved.

Developing a meta-understanding of 'human aspects' of providing palliative care

Objectives:

Our intention was to develop a meta-understanding of the ‘human aspects’ of providing palliative care. Integral to developing this meta-understanding was recognising the individuality of people, their varied involvements, situations, understandings, and responses, and the difficulty in stepping back to get a whole view of this while being in the midst of providing palliative care. We intended for this meta-understanding to inform reflections and sense-making conversations related to people’s changing situations and diverse needs.

Methods:

Using collaborative inquiry, this qualitative research was undertaken ‘with’ clinicians rather than ‘on’ them. Our team (n = 7) was composed of palliative care clinicians and researchers from a co-located rural health service and university. We explored our personal perceptions and experiences through a series of 12 meetings over 8 months. In addition, through five focus groups, we acccessed perceptions and experiences of 13 purposively sampled participants with a range of roles as carers and/or healthcare providers. Data were dialogically and iteratively interpreted.

Findings:

Our meta-understanding of ‘human aspects’ of providing palliative care, represented diagrammatically in a model, is composed of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING. ATTRIBUTES OF HUMANITY are death’s inevitability, suffering’s variability, compassion’s dynamic nature, and hope’s precariousness. ACTIONS OF CARING include recognising and responding, aligning expectations, valuing relationships, and using resources wisely. The meta-understanding is a framework to keep multiple complex concepts ‘in view’ as they interrelate with each other.

Significance of findings:

Our meta-understanding, highlighting ‘human aspects’ of providing palliative care, has scope to embrace complexity, uncertainty, and the interrelatedness of people in the midst of resourcing, requiring, and engaging in palliative care. Questions are posed for this purpose. The non-linear diagrammatic representation of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING facilitates multiple ways of engaging and revisiting palliative care situations or navigating changes within and across them.

The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

In today's industrial societies, many people die receiving professional care. Although specialist palliative and hospice care have often been identified as ideal care approaches to promote good dying, more people die receiving generalist palliative care. This integrative review examines how professional caregivers providing generalist palliative care in hospitals, nursing or private homes define good dying. Furthermore, through comparative analysis of existing empirical studies, it explores conceptual aspects in researching good dying that better reflect the social complexity of this phenomenon. Three databases (Scopus, MEDLINE, and CINAHL) were searched for peer-reviewed studies published between January 2000 and April 2020. Studies were selected if they presented original empirical findings from qualitative or quantitative studies on the perspective of professional caregivers in generalist palliative care (nurses, physicians, surgeons, clergy, and other staff) on good dying or related concepts (e.g., good death, dignity in dying, or quality of life at the end of life). 42 studies were included in the review. They identified good dying as expected, accepted and prepared dying, as free from pain and suffering, as socially embedded, as being at peace with one's life and situation, as supported with individualised and holistic care, as based upon professional cooperation and communication, and as in a peaceful and private environment. The paper concludes that the perspective of professional caregivers in generalist palliative care shares many elements of good dying with societal and specialist palliative care discourses around good dying. Through comparing the different studies, the review found that studies that explicated who benefitted from ideals and practices of good dying, questioned the dichotomous categorisation of good/bad dying, or discussed the compatibility of elements of good dying, provided more nuanced perspectives on this topic. Thus, the review calls for a more systematic analysis of these aspects in research of good dying.

The Online Representation of Palliative Care by Practice, Policy, and Advocacy Organizations: Definitional Variations and Discursive Tensions

Negative beliefs and a lack of clarity surrounding the meaning of palliative care have been widely reported as obstacles to its uptake. Information available to the public possibly contributes to this. A descriptive and discourse-theoretical analysis was conducted of information spread online by palliative care policy, advocacy, and practice organizations. Discrepancies were found in the way palliative care was defined in relation to curative, end-of-life, terminal, and supportive care. Beyond these definitional variations, meaning was generated through the representation of palliative care as a culture, connected to total care, compassion, and openness. Tensions arose around the concepts of autonomy, a natural death, and an emphasis on the quality of life away from death and dying. Overall, this study showed that the online information of palliative care is a potential source of confusion and might even contribute to its stigmatization. Insights are provided that may help improve clarity toward the public.

Instruments for the identification of patients in need of palliative care in the hospital setting: a systematic review of measurement properties

OBJECTIVE

The objective of this review was to provide a comprehensive overview of the measurement properties of the available instruments used by clinicians for identifying adults in need of general or specialized palliative care in hospital settings.

INTRODUCTION

Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging.

INCLUSION CRITERIA

We included development and validation studies that reported on measurement properties (eg, content validity, reliability, or responsiveness) of instruments used by clinicians for identifying adult patients (>18 years and older) in need of palliative care in hospital settings.

METHODS

Studies published until March 2020 were searched in four databases: Embase.com, Medline Ovid, PubMed, and CINAHL EBSCO. Unpublished studies were searched in Google Scholar, government websites, hospice websites, the Library Network of Western Switzerland, and WorldCat. The search was not restricted by language; however, only studies published in English or French were eligible for inclusion. The title and abstracts of the studies were screened by two independent reviewers against the inclusion criteria. Full-text studies were reviewed for inclusion by two independent reviewers. The quality of the measurement properties of all included studies were assessed independently by two reviewers according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

RESULTS

Out of the 23 instruments identified, four instruments were included, as reported in six studies: the Center to Advance Palliative Care (CAPC) criteria, the Necesidades Paliativas (NECPAL), the Palliative Care Screening Tool (PCST), and the Supportive and Palliative Care Indicators Tool (SPICT). The overall psychometric quality of all four instruments was insufficient according to the COSMIN criteria, with the main deficit being poor construct description during development.

CONCLUSIONS

For the early identification of patients needing palliative care in hospital settings, there is poor quality and incomplete evidence according to the COSMIN criteria for the four available instruments. This review highlights the need for further development of the construct being measured. This may be done by conducting additional studies on these instruments or by developing a new instrument for the identification of patients in need of palliative care that addresses the current gaps in construct and structural validity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020150074.

Theorising the hospice gaze: A Foucauldian collaborative ethnography of a palliative day care service

Foucault's medical gaze has only been minimally applied to palliative care through the analysis of key policy documents. This paper develops the conceptualisation of Foucault's medical gaze using empirical data gathered from a group ethnography of a hospice daycare centre. Using Foucault's medical gaze as a theoretical aporia we conceptualise the "hospice gaze". We argue the hospice gaze is the antithesis of the Foucauldian medical gaze, suggesting it operates reflexively so that professionals adapt to patients, rather than patients to professionals; that it is directed towards enabling patients and their loved ones to narrate severe illness and death in ways that develop more patient-centred narratives; and, structures the processes of care in direct resistance to the neoliberalisation of healthcare by engaging in slow practices of care with patient's bodies and minds. Finally, key to all of this is how the hospice gaze manages the spaces of care to ensure that it always and already appears slow to the patients. Therefore, the hospice gaze ensures a (re)distribution of power and knowledge that minimises the corrosive qualities of busyness and maximises the ethical potentials of slowness. We conclude by arguing that the operation of the hospice gaze should be examined in other settings where palliative care is practiced such as in-patient and home care services.

Nurses' views and applications on palliative care

PURPOSE

This study was carried out descriptively to determine the view and applications about pallative care of nurses working in a university hospital.

DESIGN AND METHODS

The data were collected with the questionnaire form: "Individual Information Form" and "Views and Appllications on Palliative Care," created by the researchers in line with the literature.

FINDINGS

A total of 96.6% of the nurses evaluated the scope of palliative care as pain relief, and the most common difficulties in care were identified as bad news (88.1%). In all, 22.0% of the nurses talked to the patient and their family about death.

PRACTICE IMPLICATIONS

It is thought that the majority of nurses are not trained in palliative care and their opinions about palliative care are affected by this situation.

Attitudes and practices towards palliative care in chronic heart failure: a survey of cardiovascular nurses and physicians

BACKGROUND

Heart failure is a chronic condition with various implications for individuals and families. Although the importance of implementing palliative care is recommended in best practice guidelines, implementation strategies are less clear.

AIMS

This study sought to; (1) determine Australian and New Zealand cardiovascular nurses and physicians' end of life care attitudes and specialist palliative care referral in heart failure and; (2) determine self-reported delivery of supportive care and attitudes towards service names.

METHODS

An electronic survey was emailed to members of four peak bodies and professional networks. Participants were also recruited through social media. Paper-based versions of the survey were completed by attendees of the 66th Cardiac Society of Australia and New Zealand Annual Scientific Meeting, August 2018.

FINDINGS

There were 113 completed responses included in the analyses. Participants were nurses (n = 75), physicians (n = 32) and allied health professionals (n = 4). Most (67%) reported they were comfortable with providing end of life care; however, fewer respondents agreed they received support for their dying patients and one-third experienced a sense of failure when heart failure progressed. Most (84-100%) participants agreed they would refer a heart failure patient later in the illness trajectory. There was a more favourable attitude towards the service name 'supportive care' than to 'palliative care'.

CONCLUSION

Comfort with end of life discussions is encouraging as it may lead to a greater likelihood of planning future care and identifying palliative care needs. Peer support and supervision may be useful for addressing feelings of failure. The use of needs-based assessment tools, adopting the service name 'supportive care' and further research focusing on primary palliative team-based approach is required to improve palliative care access.

IMPACT STATEMENT

Cardiovascular nurses and physicians are comfortable providing end of life care, but referrals to palliative care in the later stages of heart failure persists.

Factors influencing length of survival in ambulatory palliative care - a cross sectional study based on secondary data

BACKGROUND

Quality of life and patient self-determination are key elements in successful palliative care. To achieve these goals, a robust prediction of the remaining survival time is useful as it can provide patients and their relatives with information for individual goal setting including appropriate priorities. The Aim of our study was to assess factors that influence survival after enrollment into ambulatory palliative care.

METHODS

In this cross-sectional, multicenter study (n = 14 study centers) clinical records of all palliative care patients who were treated in 2017 were extracted and underwent statistical analysis. The main outcome criterion was the association of survival time with clinical characteristics such as age, type of disease, symptoms and performance status.

RESULTS

A total of 6282 cases were evaluated. Median time of survival was 26 days (95 % CI: 25-27 days). The strongest association for an increased hazard ratio was found for the following characteristics: moderate/severe weakness (aHR: 1.91; 95 % CI: 1.27-2.86) Karnofsky score 10-30 (aHR: 1.80; 95 % CI: 1.67-1.95), and age > 85 (aHR: 1.50; 95 % CI: 1.37-1.64). Surprisingly, type of disease (cancer vs. non-cancer) was not associated with a change in survival time (aHR: 1.03; 95 % CI: 0.96-1.10).

CONCLUSIONS

In this cross-sectional study, the most relevant predictor for a short survival time in specialized ambulatory palliative care was the performance status while type of disease was irrelevant to survival.

The impact of COVID-19 on palliative care workers across the world: A qualitative analysis of responses to open-ended questions

OBJECTIVE

With over two million deaths and almost 100 million confirmed cases, the COVID-19 pandemic has caused a "tsunami of suffering." Health care workers, including palliative care workers, have been severely impacted. This study explores how the COVID-19 pandemic has impacted palliative care workers around the world and describes the coping strategies they have adopted to face their specific situation.

METHOD

We conducted a qualitative analysis of written, unstructured comments provided by respondents to a survey of IAHPC members between May and June 2020. Free text was exported to MAX QDA, and a thematic analysis was performed by reading the comments and developing a coding frame.

RESULTS

Seventy-seven palliative care workers from 41 countries submitted at least one written comment, resulting in a data corpus of 10,694 words and a total of 374 coded comments. Eight main themes are emerged from the analysis: palliative care development, workforce impact, work reorganization, palliative care reconceptualization, economic and financial impacts, increased risk, emotional impact, and coping strategies.

SIGNIFICANCE OF RESULTS

The pandemic has had a huge impact on palliative care workers including their ability to work and their financial status. It has generated increased workloads and placed them in vulnerable positions that affect their emotional well-being, resulting in distress and burnout. Counseling and support networks provide important resilience-building buffers. Coping strategies such as team and family support are important factors in workers' capacity to adapt and respond. The pandemic is changing the concept and praxis of palliative care. Government officials, academia, providers, and affected populations need to work together to develop, and implement steps to ensure palliative care integration into response preparedness plans so as not to leave anyone behind, including health workers.

An Integrative Review Exploring Psycho-Social Impacts and Therapeutic Interventions for Parent Caregivers of Young People Living with Duchenne's Muscular Dystrophy

The purpose of this integrative review was to explore psycho-social impacts and therapeutic interventions for parent caregivers of young people living with Duchenne’s Muscular Dystrophy (DMD). Electronic databases were searched for research publications between 2010 and 2020. This included Medline, CINAHL, PsycINFO, ERIC, ERC, and AMED. Four central themes emerged: Living with DMD; Knowing and telling; Transitioning; and Building resilience. The impact on parents caring for a child with DMD affected all aspects of their lives, changed over time, and had identifiable peak stress points. Unmet parental information and support needs left parents struggling in their role. Transition required changes to parenting behaviors and required adaptation and resilience. It is proposed that future investment should focus on anticipating family need, targeting intervention cognizant of predictable stress points and building resilience through social community. Parents may then be better positioned to support their child in looking forward.

Definitions of Palliative Care Terms: A Consensus-Oriented Decision-Making Process

Background: Lack of consistency in palliative care language can serve as barriers when designing, delivering, and accessing high-quality palliative care services. Objective: To develop a consensus-driven and evidence-based palliative care glossary for the Health Standards Organization Palliative Care Services National Standard of Canada (CAN/HSO 13001:2020). Design: Content analysis of the Palliative Care Services standard was used to refine a list of terms. Environmental scan and rapid review were used for identification of concepts and definitions. Two meetings of consultation based on the modified Delphi approach took place among a working committee consisting of 12 health care providers, administrators, academics, and patient/family representatives. Results: Palliative approach to care, quality of life, pain and symptom management, caregivers, palliative care, life-limiting illness, and serious illness were defined by modification/adoption of existing definitions. Conclusion: A glossary of key palliative care terms was developed and included in the HSO Palliative Care Services standard, which will facilitate communication using consistent language across care settings.

A Qualitative Exploration of Seriously Ill Patients' Experiences of Goals of Care Discussions in Australian Hospital Settings

BACKGROUND

Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions.

OBJECTIVE

This study explored patients' perspectives of the GOC discussion in the hospital setting.

DESIGN

An explorative qualitative design was used within a social constructionist framework.

PARTICIPANTS

Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview.

APPROACH

Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes.

KEY RESULTS

Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most patients viewed the conversation as necessary and valued having their preferences heard. Effective communication strategies and a safe, private setting were facilitators of the GOC discussion. Deficits in any of these key elements functioned as a barrier to the process.

CONCLUSIONS

Effective communication, and patients' values and expectations set the stage for goals of care discussions; however, the environment plays a significant role. Communication skills training and education designed to equip clinicians to negotiate GOC interactions effectively are essential. These interventions must also be accompanied by systemic changes including building a culture supportive of GOC, clear policies and guidelines, and champions who facilitate uptake of GOC discussions.

Development of an international Core Outcome Set (COS) for best care for the dying person: study protocol

BACKGROUND

In contrast to typical measures employed to assess outcomes in healthcare such as mortality or recovery rates, it is difficult to define which specific outcomes of care are the most important in caring for dying individuals. Despite a variety of tools employed to assess different dimensions of palliative care, there is no consensus on a set of core outcomes to be measured in the last days of life. In order to optimise decision making in clinical practice and comparability of interventional studies, we aim to identify and propose a set of core outcomes for the care of the dying person.

METHODS

Following the COMET initiative approach, the proposed study will proceed through four stages to develop a set of core outcomes: In stage 1, a systematic review of the literature will identify outcomes measured in existing peer reviewed literature, as well as outcomes derived through qualitative studies. Grey literature, will also be included. Stage 2 will allow for the identification and determination of patient and proxy defined outcomes of care at the end of life via quantitative and qualitative methods at an international level. In stage 3, from a list of salient outcomes identified through stages 1 and 2, international experts, family members, patients, and patient advocates will be asked to score the importance of the preselected outcomes through a Delphi process. Stage 4 consists of a face-to-face consensus meeting of international experts and patient/family representatives in order to define, endorse, and propose the final Core Outcomes Set.

DISCUSSION

Core Outcome Sets aim at promoting uniform assessment of care outcomes in clinical practice as well as research. If consistently employed, a robust set of core outcomes for the end of life, and specifically for the dying phase, defined by relevant stakeholders, can ultimately be translated into best care for the dying person. Patient care will be improved by allowing clinicians to choose effective and meaningful treatments, and research impact will be improved by employing internationally agreed clinically relevant endpoints and enabling accurate comparison between studies in systematic reviews and/or in meta-analyses.

Redefining Palliative Care-A New Consensus-Based Definition

CONTEXT

The International Association for Hospice and Palliative Care developed a consensus-based definition of palliative care (PC) that focuses on the relief of serious health-related suffering, a concept put forward by the Lancet Commission Global Access to Palliative Care and Pain Relief.

OBJECTIVE

The main objective of this article is to present the research behind the new definition.

METHODS

The three-phased consensus process involved health care workers from countries in all income levels. In Phase 1, 38 PC experts evaluated the components of the World Health Organization definition and suggested new/revised ones. In Phase 2, 412 International Association for Hospice and Palliative Care members in 88 countries expressed their level of agreement with the suggested components. In Phase 3, using results from Phase 2, the expert panel developed the definition.

RESULTS

The consensus-based definition is as follows: Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers. The definition includes a number of bullet points with additional details as well as recommendations for governments to reduce barriers to PC.

CONCLUSION

Participants had significantly different perceptions and interpretations of PC. The greatest challenge faced by the core group was trying to find a middle ground between those who think that PC is the relief of all suffering and those who believe that PC describes the care of those with a very limited remaining life span.

Self-management support? Listening to people with complex co-morbidities

OBJECTIVES

The study aimed to explore how people with complex, established co-morbidities experience long-term condition care in New Zealand. Despite the original conception as appropriate for people with early stage disease, in New Zealand the self-management approach dominates the care provided to people at all stages of diagnosis with long-term conditions, something reinforced through particular funding mechanisms.

METHODS

A multiple case study followed the lives of 16 people with several long-term conditions. Data collection comprised two interviews, four weekly contacts with patients over an 18-month period and an interview with their primary health care clinicians.

RESULTS

This paper reveals a cohort of tired, distracted patients struggling to manage their lives in the face of multiple conflicting challenges, with insufficient energy for the level of personal agency required to deal with the self-management approach.

DISCUSSION

Participants described aspects of care received, which does meet their needs but sit outside the self-management approach, that resonate with the ideas behind current approaches to palliative care. The potential of an approach to care built upon these ideas is explored as a more compassionate, effective way of meeting the needs of people with advanced, multiple long-term conditions. Further research is warranted to explore the acceptability of such an approach.

Death without distress? The taboo of suffering in palliative care

Palliative care (PC) names as one of its central aims to prevent and relieve suffering. Following the concept of "total pain", which was first introduced by Cicely Saunders, PC not only focuses on the physical dimension of pain but also addresses the patient's psychological, social, and spiritual suffering. However, the goal to relieve suffering can paradoxically lead to a taboo of suffering and imply adverse consequences. Two scenarios are presented: First, PC providers sometimes might fail their own ambitions. If all other means prove ineffective terminal sedation can still be applied as a last resort, though. However, it may be asked whether sedating a dying patient comes close to eliminating suffering by eliminating the sufferer and hereby resembles physician-assisted suicide (PAS), or euthanasia. As an alternative, PC providers could continue treatment, even if it so far prove unsuccessful. In that case, either futility results or the patient might even suffer from the perpetuated, albeit fruitless interventions. Second, some patients possibly prefer to endure suffering instead of being relieved from it. Hence, they want to forgo the various bio-psycho-socio-spiritual interventions. PC providers' efforts then lead to paradoxical consequences: Feeling harassed by PC, patients could suffer even more and not less. In both scenarios, suffering is placed under a taboo and is thereby conceptualised as not being tolerable in general. However, to consider suffering essentially unbearable might promote assisted dying not only on an individual but also on a societal level insofar as unbearable suffering is considered a criterion for euthanasia or PAS.

A Concept Analysis of Neonatal Palliative Care in Nursing: Introducing a Dimensional Analysis

Despite the increasing need for neonatal palliative care, it is not adequately implemented in practice. This analysis aimed to clarify the dimension of the neonatal palliative care concept to increase understanding of the concept to give more insight into clinical practice. Using dimensional analysis methodology, 46 English language papers from 2001-2018 were analyzed. The coding of the literature for the perspective, context, conditions, process, and consequences of the concept was completed. Five dimensions informed the conceptualization of this concept and interrelationships among their themes/sub-themes were presented in the matrix named, "improving quality of life and death". Within the family-centered care perspective and under different conditions/contexts through the processes of neonate's comfort and providing holistic care, the consequences of this care were improving quality of life/a good death. Family-centered care was the fundamental dimension and essential to achieving the consequences. The other dimensions of context, conditions, and processes were also affected by the family's needs, preferences, culture, and expectations. This analysis reinforces that neonatal palliative care is a multidimensional concept. To provide the standard of neonatal palliative care an integrated plan to get together many stakeholders including community, parents, clinical staff, policymakers, insurance authorities, health care systems, and education system is required. All NICUs should have neonatal palliative care-trained nurses and protocols with a family-centered care approach to focus on the quality of life of neonates with life-threatening conditions from diagnosis of disease to death. Regular training and educational courses on neonatal palliative care and family-centered care principles can make nurses more sensitive to their advocacy role.

A Review and Considerations on Palliative Care Improvements for African Americans With Cancer

Hospice and Palliative care benefits are infrequently realized by African American patients with cancer. With the increasing recognition of the critical role of early utilization of palliative services for optimal and quality patient care, it is important to acknowledge disparities and barriers to access that minority patients may face. The purpose of this paper is to discuss the status of palliative care delivery for African American patients within the structure and framework of the clinical practice guideline domains established by the National Consensus Project for Palliative Care. This perspectives paper describes the different aspects of palliative care and the interplay with African American culture. Here, we also attempt to identify the multilevel barriers (health care system and provider level) to palliative care among African Americans as a required step toward decreasing the disparities in access, coverage, utilization, and benefit of palliative care. Furthermore, this paper may serve as an educational guide for health care workers who care for African American patients with cancer.

Palliative care utilization in oncology and hemato-oncology: a systematic review of cognitive barriers and facilitators from the perspective of healthcare professionals, adult patients, and their families

Background

Despite the high potential to improve the quality of life of patients and families, palliative care services face significant obstacles to their use. In countries with high-resource health systems, the nonfinancial and nonstructural obstacles to palliative care services are particularly prominent. These are the cognitive barriers -knowledge and communication barriers- to the use of palliative care. To date no systematic review has given the deserved attention to the cognitive barriers and facilitators to palliative care services utilization.

This study aims to synthesize knowledge on cognitive barriers and facilitators to palliative care use in oncology and hemato-oncology from the experiences of health professionals, patients, and their families.

Methods

A systematic review was conducted. PubMed, PsycINFO, International Association for Hospice and Palliative Care/Cumulative Index of Nursing and Allied Health Literature (IAHPC/CINAHL), and Communication & Mass Media Complete (CMMC) were systematically searched for the main core concepts: palliative care, barriers, facilitators, perspectives, points of view, and related terms and synonyms. After screening of titles, abstracts, and full-texts, 52 studies were included in the qualitative thematic analysis.

Results

Four themes were identified: awareness of palliative care, collaboration and communication in palliative care-related settings, attitudes and beliefs towards palliative care, and emotions involved in disease pathways. The results showed that cognitive barriers and facilitators are involved in the educational, social, emotional, and cultural dimensions of palliative care provision and utilization. In particular, these barriers and facilitators exist both at the healthcare professional level (e.g. a barrier is lack of understanding of palliative care applicability, and a facilitator is strategic visibility of the palliative care team in patient floors and hospital-wide events) and at the patient and families level (e.g. a barrier is having misconceptions about palliative care, and a facilitator is patients’ openness to their own needs).

Conclusions

To optimize palliative care services utilization, awareness of palliative care, and healthcare professionals’ communication and emotion management skills should be enhanced. Additionally, a cultural shift, concerning attitudes and beliefs towards palliative care, should be encouraged.

[Assessing the Benefit of Palliative Care in Germany - Perspective of Patients, Relatives and Professionals]

BACKGROUND

The evaluation of complex interventions such as palliative care is challenging. Methods guidance such as the guidance documents of the Integrated Health Technology Assessment for the Evaluation of Complex Technologies (INTEGRATE-HTA) project help address specific challenges. The INTEGRATE-guidance was developed cooperatively by various international stakeholders and it was applied in a case study on palliative care. The presented study was part of the INTEGRATE-HTA project. ObjectivesThe objective was to identify important assessment aspects of palliative care in Germany from the perspective of patients, relatives and professional providers.

METHODS

Applying the structured consensus method of the Improved Nominal Group Technique, we conducted interviews with two focus groups - one with relatives and one with professionals. Additionally, we conducted 4 interviews with patients. We used an open coding procedure to analyze the data and a dialogical approach to validate the results.

RESULTS

8 assessment aspects were found to be important. These are the definition and legitimacy of the term benefit, understanding of palliative care, patient-centered and holistic care approach, access to palliative care, continuity and flexibility of care, education of palliative care providers, and multidisciplinary approach. A central point was the need to address the intervention in its complexity and to include interactions between the different components.

CONCLUSIONS

To be able to integrate various models and different perspectives of palliative care, it is important to have the involvement of different stakeholders. This also enhances the incorporation of important aspects during the development of assessment instruments.

The good death and the institutionalisation of dying: An interpretive analysis of the Austrian discourse

The institutionalisation of dying is recurrently assessed as adverse to a good death. However, a majority of people die in institutions such as hospitals or nursing homes and end-of-life care at home is more and more professionally supported. This article analyses how the discursive production of dying, the good death, and the issue of institutionalisation at the end of life are interrelated. The study empirically investigates a parliamentary enquiry on dying with dignity that took place in Austria between 2014 and 2015. It employs the Sociology of Knowledge Approach to Discourse to analyse parliamentary documents and minutes, written statements submitted by individuals and organisations, as well as newspaper articles. Data analysis shows a restrictive and a permissive normative position considering both killing on request and assisted suicide. Apart from their different political demands, they both reproduce a discourse constructing dying as a longer lasting and painful process striking old or ill people. In order to enable a good death, the dying person needs comprehensive support that the informal social environment is incapable to provide. Thereby, institutionalisation is associated with negative characteristics and at the same time identified as requirement for a good death considering its role in pain management and provision of care. The analysis interprets the call for institutionalisation in the context of medicalisation and the central role of physicians to alleviate pain. The article proposes a differentiated view on institutionalisation processes and practices in end-of-life care, also reflecting the potential of institutionalisation to obstruct fundamental societal transformation.

Palliative care provision in long-term care facilities differs across Europe: Results of a cross-sectional study in six European countries (PACE)

BACKGROUND

While the need for palliative care in long-term care facilities is growing, it is unknown whether palliative care in this setting is sufficiently developed.

AIM

To describe and compare in six European countries palliative care provision in long-term care facilities and to assess associations between patient, facility and advance care planning factors and receipt and timing of palliative care.

DESIGN

Cross-sectional after-death survey regarding care provided to long-term care residents in Belgium, England, Finland, Italy, the Netherlands and Poland. Generalized estimating equations were used for analyses.

SETTING/PARTICIPANTS

Nurses or care assistants who are most involved in care for the resident.

RESULTS

We included 1298 residents in 300 facilities, of whom a majority received palliative care in most countries (England: 72.6%-Belgium: 77.9%), except in Poland (14.0%) and Italy (32.1%). Palliative care typically started within 2 weeks before death and was often provided by the treating physician (England: 75%-the Netherlands: 98.8%). A palliative care specialist was frequently involved in Belgium and Poland (57.1% and 86.7%). Residents with cancer, dementia or a contact person in their record more often received palliative care, and it started earlier for residents with whom the nurse had spoken about treatments or the preferred course of care at the end of life.

CONCLUSION

The late initiation of palliative care (especially when advance care planning is lacking) and palliative care for residents without cancer, dementia or closely involved relatives deserve attention in all countries. Diversity in palliative care organization might be related to different levels of its development.

Using the Term "Palliative Care": International Survey of How Palliative Care Researchers and Academics Perceive the Term "Palliative Care"

Background: The term "palliative care" (PC) has often been found to have a negative connotation leading some to suggest rebranding and some services to change their name. Perceptions of the PC community about the term remain largely unexplored. Objective: To explore how PC researchers/academics perceive the term is the objective of this study. Design: This is a cross-sectional survey of attendees to the 10th World Research Congress of the EAPC. The questionnaire covered areas of academic activity, including the use of the term. We analyzed data through descriptive and nonparametric statistics and open responses through content analysis. Participants: Academics and researchers in PC were the participants in this study. Results: Of 318 respondents, the majority were women (65%), physicians (48%), and had a postgraduate degree (90%). For 40%, the term hindered the positioning of PC, 28% worried about using the term, and 55% did not discuss these difficulties. We found significant differences between responses and several demographics (e.g., younger age and higher likelihood of worrying about the term). Through open responses, we identified that the term is widely in use, and that its limitations are seen as a cultural by-product, and not as something that a name change would solve. Conclusions: Senior PC academics, researchers, and clinicians have an onus to ensure that colleagues with limited PC experience have the opportunity to discuss and explore the impact of the term on the practice of research. Regarding the term itself, the community's views are conclusive: although using the term will remain a difficult task, the field's identity is in the name.

Ethics and patient and public involvement with children and young people

Patient and public involvement (PPI) is important both in research and in quality improvement activities related to healthcare services . While PPI activities do not require formal ethical approval, they can raise a number of ethical concerns, through the introduction of complex technical medical concepts, challenging language or sensitive subject areas. There is very little published literature to guide ethical practice in this area. We have been conducting PPI with children and young people throughout a research study in paediatric palliative care. PPI started during the application process and continued to guide and shape the research as it progressed. Ethical issues can arise at any time in PPI work. Although many can be predicted and planned for, the nature of PPI means that researchers can be presented with ideas and concepts they had not previously considered, requiring reflexivity and a reactive approach. This paper describes how we considered and addressed the potential ethical issues of PPI within our research. The approach that emerged provides a framework that can be adapted to a range of contexts and will be of immediate relevance to researchers and clinicians who are conducting PPI to inform their work.

The conceptual understanding of pediatric palliative care: a Swiss healthcare perspective

Background

Health care providers’ perception of pediatric palliative care might negatively influence timely implementation. The aim of the study was to examine understanding of and attitudes towards pediatric palliative care from the perspective of health care providers working in pediatric oncology in Switzerland to promote the timely implementation of pediatric palliative care.

Methods

Five mixed focus groups were conducted with 29 health care providers (oncologists, nurses, psychologists, and social workers) at five Swiss pediatric oncology group centers. The focus group interviews were analyzed using thematic coding.

Results

Most participants associated pediatric palliative care with non-curative treatment. They regularly reported difficulties in addressing palliative care services to families due to the strong stigma surrounding this term. They also thought that the notion of palliative care is very much linked to a policy context, and difficult to reconcile with children’s everyday life. To overcome these obstacles many participants used synonyms such as comfort or supportive care. A few providers insisted on the need of using palliative care and reported the importance of positive “word of mouth”.

Conclusions

The use of synonyms might be a pragmatic approach to overcome initial barriers to the implementation of palliative care in pediatrics. However, this tactic might ultimately prove to be ineffective as these terms might acquire the same negative connotations as palliative care. Positive word-of-mouth by satisfied families and healthcare providers might be a more sustainable way to advocate for pediatric palliative care than replacing it with a euphemistic term.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.