Predictive model of death acceptance among Thai Buddhist patients with chronic diseases

BACKGROUND

A chronic disease generally leads to a decline in patients' health and shortened lives. This cross-sectional study examined death acceptance and related factors among Thai Buddhists diagnosed with chronic diseases.

METHODS

A convenience sample of 423 patients recruited from five tertiary hospitals in Thailand completed self-reported questionnaires.

RESULTS

Respondents reported a moderately high level of death acceptance, with a mean score of 39.59 ± 6.52 (out of 48.00). Death anxiety, Buddhist practices, Buddhist belief, and self-efficacy explained 28% of the variance of death acceptance (R2 = 0.28; F = 25.27; p < 0.001). Among variables, Buddhist belief was the strongest predictor of death acceptance (β = 0.26, t = 5.74, p < 0.01), followed by death anxiety (β = -0.23, t = -4.84, p < 0.05).

CONCLUSIONS

Investigation of additional variables is recommended to enhance the model's predictability. Longitudinal studies on how Buddhists' death acceptance changes with disease chronicity are needed to understand this phenomenon fully. Examining whether a causal relationship exists between death anxiety and death acceptance is also recommended.

CLINICAL TRIAL NUMBER

Not applicable.

Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers

Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals. Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed. Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public. Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients’ values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.

Unmet needs of patients with cancer in their last year of life as described by caregivers in a developing world setting: a qualitative study

BACKGROUND

Palliative care is in its infancy in most of the developing world. We set out to explore the lived experiences of families and caregivers of recently deceased cancer patients in Trinidad and Tobago and to determine the unmet needs of the patients and what recommendations could be derived to improve the current services.

METHODS

A phenomenological approach with purposeful sampling was used. Participants were referred by key health professionals. Face-to-face interviews were conducted. Interviews were transcribed verbatim, with analysis and data collection occurring concurrently. Thematic content analysis was used to determine common domains, themes and sub-themes.

RESULTS

Interviews were completed with 15 caregivers. All were spouses or children of the deceased. Ages of the deceased ranged from 43 to 93, the average being 65.5 years. The deceased experienced a variety of cancers including lung, colorectal and oesophageal. Unmet needs were identified under 4 domains of institutions, community, the family unit and the wider society. Institutional unmet needs were delayed diagnosis and treatment and poor inter-institution coordination. Medical and nursing care failed in the areas of health care providers' attitudes, pain management and communication. The family unit lacked physical and psychosocial support for the caregiver and financial aid for the family unit. Societal needs were for public education to address myths and cultural beliefs around cancer.

CONCLUSION

There is need for systemic interventions to improve the care of those dying from cancer in Trinidad and Tobago. Stakeholders need to commit to palliative care as a public health priority, implementing education, planning services and mobilizing community resources.

Care Toward the End of Life in Older Populations and Its Implementation Facilitators and Barriers: A Scoping Review

PURPOSE

To inform health system improvements for care of elderly populations approaching the end of life (EOL) by identifying important elements of care and implementation barriers and facilitators.

DESIGN

A scoping review was carried out to identify key themes in EOL care. Articles were identified from MEDLINE, the Cochrane Library, organizational websites, and internet searches. Eligible publications included reviews, reports, and policy documents published between 2005 and 2016. Initially, eligible documents included reviews or reports concerning effective or important models or components of EOL care in older populations, and evidence was thematically synthesized. Later, other documents were identified to contextualize implementation issues.

RESULTS

Thematic synthesis using 35 reports identified key features in EOL care: (1) enabling policies and environments; (2) care pathways and models; (3) assessment and prognostication; (4) advance care planning and advance directives; (5) palliative and hospice care; (6) integrated and multidisciplinary care; (7) effective communication; (8) staff training and experience; (9) emotional and spiritual support; (10) personalized care; and (11) resources. Barriers in implementing EOL care include fragmented services, poor communication, difficult prognostication, difficulty in accepting prognosis, and the curative focus in medical care.

CONCLUSIONS

Quality EOL care for older populations requires many core components but the local context and implementation issues may ultimately determine if these elements can be incorporated into the system to improve care. Changes at the macro-level (system/national), meso-level (organizational), and micro-level (individual) will be required to successfully implement service changes to provide holistic and person-centered EOL care for elderly populations.

Approaching End-of-Life Care in Organ Transplantation: The Impact of Transplant Patients' Death and Dying

Despite the success of transplantation, many transplant candidates and transplant recipients die each year. Some die awaiting transplants and some die months or years after receiving an organ. Quality end-of-life care can play a valuable role in easing the impact of death and dying in transplantation, as it focuses on enhancing patients' quality of life near death. Quality end-of-life care recognizes the values and preferences of patients and their families, and involves a process of shared decision making about patients' healthcare treatment in collaboration with healthcare practitioners. Advance care planning involves discussions with patients about their wishes and values about care, in the event that the patient becomes incapable of making such decisions. This article focuses on the application to transplantation of quality end-of-life care and advance care planning and identifies the effects that death and dying of transplant patients have on others. The information herein encourages healthcare practitioners to view and deliver quality end-of-life care as part of transplant patients' overall treatment management.

Relationship Quality in Non-Cognitively Impaired Mother-Daughter Care Dyads: A Systematic Review

More than 60 million Americans provide care to a family member; roughly two thirds are women providing care to aging mothers. Despite the protective nature of relationship quality, little attention has been given to its role in mother-daughter care dyads, particularly in mothers without cognitive impairment. A systematic appraisal of peer-reviewed, English language research was conducted. Nineteen articles met criteria. When relationship quality is positive, mother-daughter dyads enjoy rewards and mutuality, even when conflict occurs. Daughters grow more emotionally committed to mothers' over the care trajectory, despite increasing demands. Daughters' commitment deepens as mothers physically decline, and mothers remain engaged, emotional partners. When relationship quality is ambivalent or negative, burden, conflict, and blame conspire, creating a destructive cycle. Avenues for continuing study, including utilizing the dyad as the unit of analysis, troubled dyads, longitudinal assessment, and end of life context, are needed before interventions to improve mother-daughter relationship quality may be successfully implemented.

Assessing family members' satisfaction with information sharing and communication during hospital care at the end of life

CONTEXT

Despite the fact that most deaths occur in hospital, problems remain with how patients and families experience care at the end of life when a death occurs in a hospital.

OBJECTIVES

(1) assess family member satisfaction with information sharing and communication, and (2) examine how satisfaction with information sharing and communication is associated with patient factors.

METHODS

Using a cross-sectional survey, data were collected from family members of adult patients who died in an acute care organization. Correlation and factor analysis were conducted, and internal consistency assessed using Cronbach's alpha. Linear regression was performed to determine the relationship among patient variables and satisfaction on the Information Sharing and Communication (ISC) scale.

RESULTS

There were 529 questionnaires available for analysis. Following correlation analysis and the dropping of redundant and conceptually irrelevant items, seven items remained for factor analysis. One factor was identified, described as information sharing and communication, that explained 76.3% of the variance. The questionnaire demonstrated good content and reliability (Cronbach's alpha 0.96). Overall, family members were satisfied with information sharing and communication (mean total satisfaction score 3.9, SD 1.1). The ISC total score was significantly associated with patient gender, the number of days in hospital before death, and the hospital program where the patient died.

CONCLUSIONS

The ISC scale demonstrated good content validity and reliability. The ISC scale offers acute care organizations a means to assess the quality of information sharing and communication that transpires in care at the end of life.

Researching “Good Death” in a Hong Kong Palliative Care Program: A Clinical Data-Mining Study

This study operationalizes and assesses the percentage of “good deaths” achieved among Chinese cancer patients in a palliative care program, the profile of these patients, the relationship between patients with a good death and psychosocial factors, and the differences in background factors, and physical and psychosocial conditions between patients who experienced a good death and those who did not. Clinical data mining was the research method used. Records of deceased cancer patients between 2003 and 2005 in a palliative care unit were the sole data source. Good death was operationally defined as the patient's record indicating no pain (physical) or anxiety (psychological), and having open and honest communication with family (social) in the final assessment by the Support Team Assessment Schedule (STAS) just before death. Using these criteria, about one-fifth of patients (21.5%; 137 out of 638) experienced a good death. Those with a good death were significantly older and were in palliative care longer. Their records also indicated lower levels of constipation, insomnia, oral discomfort, and family anxiety at their first and at their final STAS assessments. Good death was positively associated with recorded indicators of fullness in life, caregivers' acceptance and support, and negatively with reported feelings of upset about changes in the course of their illness. The results heighten awareness among social workers and other healthcare professionals about the value of good death in patients in palliative care. This empirically-based awareness can foster professionals' ability to set intervention objectives to help patients in palliative care achieve this universally accepted goal.

Goals set in the land of the living/dying: a longitudinal study of patients living with advanced cancer

A longitudinal qualitative research study was undertaken to provide an understanding of a prolonged experience of advanced cancer, as seen through the eyes of dying individuals. Using a variant of the grounded theory method, the authors theoretically sampled, from outpatient clinics in a large comprehensive cancer treatment center, 27 patients with either advanced lung or gastrointestinal cancer who had an expected survival of up to 2 years. The authors conducted a total of 54 interviews with these patients to learn of their experience of advanced cancer. The authors represent their experience with the core category: striving to grow in the land of the living/dying, symbolizing their sense of finding themselves in a borderland between life and death where their efforts focused on 3 common goals. controlling dying, valuing life in the present, and creating a living legacy. They provide a longitudinal account of how these goals were addressed throughout the illness trajectory and discuss the theoretical and clinical implications of this understanding for the experience of dying from advanced cancer.

A comparison of palliative care outcome measures used to assess the quality of palliative care provided in Residential Aged Care Facilities: a systematic review

BACKGROUND

Provision of palliative care in residential aged care facilities (RACFs) is important but limited research has been undertaken to investigate the most appropriate outcome measures for use in this setting.

OBJECTIVE

This systematic review aimed tomeasure the psychometric properties (reliability/validity) and feasibility of palliative outcome measures used to assess the quality of palliative care provided in residential aged care facilities.

INCLUSION CRITERIA

This review considered studies reporting on the psychometric properties of palliative care outcome measures that have been used in assessing the quality of palliative care provided in residential aged care facilities, including support to family. Measures may be those completed by a health professional, the person receiving care or their family.

SEARCH STRATEGY

The search strategy aimed to identify both English language published and unpublished studies. A three-step strategy was followed, in which the initial phase consisted of searches of the CINAHL, MEDLINE and PsycINFO databases using keywords or terms. Second, a more extensive search was performed using the appropriate Subject Headings and/or keywords/phrase/strategy for several major databases. Finally, the reference lists or bibliographies of identified reports and articles were hand searched for additional relevant studies.

METHODOLOGICAL QUALITY

Included studies were assessed by two independent reviewers for methodological quality prior to inclusion in the review using an appraisal checklist developed for the review based on the review methods of Zwakhalen et al to evaluate validity, reliability and feasibility.

RESULTS

The database and hand searches yielded 441 articles for review of which 17 were duplicates leaving 422 abstracts which were critically appraised for relevance to the review based on the title and abstract. After applying the inclusion and exclusion criteria, twenty three abstracts were retained and full articles were retrieved for screening by the two authors. Of these twenty three articles, ten were included in the final review. The ten articles provide specific information on the psychometric properties of ten outcome measures. Of the ten included articles, four report on the psychometric properties of the outcome measure used exclusively within the residential aged care setting while the remaining six measures report the use in a sub-population. The Family Perceptions of Care Scale (FPCS) is considered by the authors as the most suitable outcome measure for use in RACFs. The FPCS has a number of properties that has led to its preferred selection, in particular the development and testing of the scale which occurred exclusively in the RACF population. This scale has excellent content validity, covering all essential domains of palliative care. It has a robust factor structure and is simple to administer and score. Of the remaining nine measures, a further two were also considered suitable for measuring quality of palliative care in RACFs. These are the Quality of Dying in Long Term Care (QOD-LTC) scale and the Toolkit Interview.

CONCLUSION

Based on psychometric qualities, the outcome measure of choice from this review is the Family Perceptions of Care Scale although further psychometric and clinical research needs to be conducted. Limitations regarding the use of outcome measures for assessing quality in this setting include reliance on proxy ratings and limited psychometric testing for some of the measures specifically in the RACF population.

Synthesis of qualitative research and evidence-based nursing

Evidence-based nursing is central to nursing practice. Systematic reviews have played a key part in providing evidence for decision making in nursing. Traditionally, these have consisted of syntheses of randomised controlled trials. New approaches to combining research include the synthesis of qualitative research. This article discusses the development of research synthesis as a method for creating evidence of effectiveness identified in quantitative research; more effective use of primary data; enhancing the generalizability of qualitative research; the identification of future nursing research topics.

Caregiver Objective Burden and Assessments of Patient-Centered, Family-Focused Care for Frail Elderly Veterans

PURPOSE

There is a growing consensus that quality of care for frail elders should include family and be evaluated in terms of patient-centered, family-focused care (PCFFC). Family caregivers are in a unique and sometimes sole position to evaluate such care. In the context of caring for physically frail elders, this study examined the extent to which objective burden was associated with caregiver perceptions of PCFFC and the extent to which it mediated the influence of other variables on perceptions of PCFFC.

DESIGN AND METHODS

In a study of frail elderly veterans receiving care in U.S. Department of Veterans Affairs ambulatory primary care clinics, informal caregivers assessed quality of care with 13 questions. Factor analysis of these items revealed an eight-item scale that specifically assessed PCFFC (alpha =.90). Regression analysis identified variables associated with caregiver (N = 210) assessments of PCFFC and the potential mediating effect of objective burden.

RESULTS

Caregiver assessments of PCFFC were positively associated with care recipient instrumental activity of daily living limitations (p =.04) and perspectives on the quality of their own patient care (p <.001). Greater objective burden was negatively associated with caregiver assessments of PCFFC (p <.001) and mediated (i.e., reduced) the relationship between care recipient perceptions of the quality of their own patient care and caregiver assessments of PCFFC (DeltaR(2) =.06).

IMPLICATIONS

These findings support recommendations for conducting caregiver assessments as part of routine care and highlight the importance of measuring objective burden and expectations for PCFFC in assisting physically frail elders. Primary care providers will require additional training in order to effectively implement and translate such caregiver assessments into clinical practice improvement.

How Well Do Family Caregivers Cope after Caring for a Relative with Advanced Disease and How Can Health Professionals Enhance their Support?

BACKGROUND

Support for families during a person's advanced disease and also into the bereavement period is a major component of palliative care. However, because of the gaps in bereavement research in this area, there is a lack of evidence-based direction for health professionals.

PURPOSE

This study sought to explore family caregiver perceptions of their relative's death and assess how well they were coping. Caregivers were also asked to identify which health professional strategies helped them prepare for and respond to their relative's death.

METHODS

Two months after their relative's death primary family caregivers (n=45) of patients with advanced cancer completed a structured interview and were also assessed to determine if they were confronted by traumatic grief.

RESULTS

Seven percent of caregivers were confronted by traumatic grief; most caregivers perceived they were coping reasonably well and could identify positive outcomes related to their experience. Caregivers noted the significant benefits of receiving comprehensive information to prepare them for the future and expressed appreciation for the support provided by specialist palliative care services.

CONCLUSIONS

There is a large body of literature that highlights the negative consequences of being a family caregiver to a person with advanced disease. The sample population in this study, however, seemed to be reasonably well functioning; the results of the study were therefore somewhat surprising. A research agenda and key clinical implications are outlined in order to aid direction in targeting bereavement interventions.