Attending to Methodological Challenges in Qualitative Research to Foster Participation of Individuals with Chronic Critical Illness and Communication Impairments

End of life decision making when home mechanical ventilation is used to sustain breathing in Motor Neurone Disease: patient and family perspectives

BACKGROUND

Motor Neurone Disease (MND) leads to muscle weakening, affecting movement, speech, and breathing. Home mechanical ventilation, particularly non-invasive ventilation (NIV), is used to alleviate symptoms and support breathing in people living with MND. While home mechanical ventilation can alleviate symptoms and improve survival, it does not slow the progression of MND. This study addresses gaps in understanding end-of-life decision-making in those dependent on home mechanical ventilation, considering the perspectives of patients, family members, and bereaved families.

METHODS

A UK-wide qualitative study using flexible interviews to explore the experiences of people living with MND (n = 16), their family members (n = 10), and bereaved family members (n = 36) about the use of home mechanical ventilation at the end of life.

RESULTS

Some participants expressed a reluctance to discuss end-of-life decisions, often framed as a desire to "live for the day" due to the considerable uncertainty faced by those with MND. Participants who avoided end-of-life discussions often engaged in 'selective decision-making' related to personal planning, involving practical and emotional preparations. Many faced challenges in hypothesising about future decisions given the unpredictability of the disease, opting to make 'timely decisions' as and when needed. For those who became dependent on ventilation and did not want to discuss end of life, decisions were often 'defaulted' to others, especially once capacity was lost. 'Proactive decisions', including advance care planning and withdrawal of treatment, were found to empower some patients, providing a sense of control over the timing of their death. A significant proportion lacked a clear understanding of the dying process and available options.

CONCLUSIONS

The study highlights the complexity and evolution of decision-making, often influenced by the dynamic and uncertain nature of MND. The study emphasises the need for a nuanced understanding of decision-making in the context of MND.

When chronic critical illness is a family affair: A multi-perspective qualitative study of family involvement in long-term care

OBJECTIVE

Those with chronic critical illness (CCI) remain dependent on life-sustaining treatments and increasingly reside in long-term care facilities equipped to meet their needs. The nature of family involvement in care remains undetermined thwarting approaches to mitigate poor family outcomes. The research objective was to explicate family involvement in the care of an individual with CCI who resides in long-term care.

METHODS

In this qualitative research, we used thematic analysis and constant comparative techniques to analyze data from interviews with 38 participants: 11 family members, 6 residents with CCI, and 21 healthcare providers.

RESULTS

Involvement in care entailed family: (1) reorienting their life despite the stress and emotional toll; (2) assuming responsibility for meaningful activities and management of practical matters, yet struggling alone; (3) advocating for care by being present, reminding and pushing, and picking their battles; and (4) figuring out how to contribute to nursing care, but with unclear expectations.

DISCUSSION

The burden of family caregiving was substantial, contrasting the assumption that family are relieved of their caregiver responsibilities when the patient with CCI is in a care facility. Research to address unmet family needs specific to their roles and responsibilities could potentially improve family outcomes and is warranted.

Control in the absence of choice: A qualitative study on decision-making about gastrostomy in people with amyotrophic lateral sclerosis, caregivers, and healthcare professionals

BACKGROUND

Gastrostomy is recommended in amyotrophic lateral sclerosis for long-term nutritional support, however, people with amyotrophic lateral sclerosis and healthcare professionals perceive decision-making as complex.

METHOD

To explore their perspectives on decision-making regarding gastrostomy, we used semi-structured interviews with people with amyotrophic lateral sclerosis, who had made a decision, and their caregivers; healthcare professionals were interviewed separately. Interviews were transcribed and analyzed thematically.

RESULTS

In 14 cases, 13 people with amyotrophic lateral sclerosis and 12 caregivers were interviewed; and in 10 of these cases, 5 healthcare professionals. Participants described decision-making on gastrostomy as a continuous process of weighing (future) clinical need against their values and beliefs in coming to a decision to accept or reject gastrostomy, or to postpone decision-making, while being supported by loved ones and healthcare professionals. Participants described gastrostomy as inevitable, but retained agency through control over the timing of decision-making. They said physical necessity, experiences of loss and identity, and expectations about gastrostomy placement were important factors in decision-making. Decision-making was described as a family affair, with caregivers supporting patient choice. healthcare professionals supported people with amyotrophic lateral sclerosis during the decision-making process and respected their autonomy and values. People with amyotrophic lateral sclerosis stressed the importance of adequate information on the procedure and the benefits.

CONCLUSION

People with amyotrophic lateral sclerosis feel in control of decision-making on gastrostomy if they are able to make their own choice at their own pace, supported by loved ones and healthcare professionals. Person-centered decision-making on gastrostomy requires early information exchange and repeated discussions with people with amyotrophic lateral sclerosis and their caregivers, incorporating their values and respecting patient choice.

A framework for selecting data generation strategies in qualitative health research studies

BACKGROUND

Qualitative health research has the potential to answer important applied health research questions to inform nutrition and dietetics practice, education and policy. Qualitative health research is a distinct subdiscipline of qualitative inquiry that purposefully draws upon the context of healthcare and emphasises health and wellness.

METHODS

Qualitative health research is defined by two parameters: (1) the focus of the study and (2) the methods used. When considering the methods to be used, decisions are required about the type of data to be generated (e.g., transcripts, images and notes) and the process involved in data generation (e.g., interviews, elicitation strategies and observations) to answer the research question(s). Drawing upon examples from nutrition and dietetics literature, this paper provides a framework to support decision-making for nutrition and dietetics researchers and clinician researchers designing conducting qualitative health research.

RESULTS

The guiding questions of the framework include: What types of data will be generated? Who is involved in data generation? Where will data generation occur? When will data generation occur? How will data be recorded and managed? and How will participants' and researchers' emotional safety be promoted?

CONCLUSION

Questions about the types of data, those involved, where and when, as well as how safety can be maintained in data generation, not only support a more robust design and description of data generation methods but also keep the person at the centre of the research.

Connectedness in the time of COVID-19: Reddit as a source of support for coping with suicidal thinking

The COVID-19 pandemic is adversely impacting suicidality at a population level, with consequences resulting from a variety of pandemic-driven disruptions, including social activities and connectedness. This paper uses a single case study design to explore how members of the Reddit r/COVID19_support community create a sense of connectedness among those who have suicidal thoughts due to the pandemic. Data were gathered from posts to the r/COVID19_support subreddit forum from February 2020 through December 2020. The second step of Klonsky and May's (2015) Three-Step Theory (3ST) of suicide, connectedness as a key protective factor, was used as the theoretical framework. This study explored r/COVID19_support's constructed environment, users' dialogical interactions, and the four primary tenets of connectedness as proposed by Klonsky and May - Purpose and Meaning, Relationships, Religiosity, and Employment. Findings demonstrate a deep sense of connectedness for online community members. Relationships and Purpose and Meaning featured as the most salient sources of connectedness within this subreddit, whereas Religiosity was rarely discussed, and Employment was often spoken of in negative terms (i.e., creating mental distress, rather than facilitating connectedness). Contributors' responses offered various opportunities for connectedness both on- and off-line. Safe online spaces, such as r/COVID19_support, can serve as a protective factor amid suicidality, facilitating connectedness, and thereby helping to curtail suicidal thoughts from advancing to suicidal actions. This subreddit and similar online spaces can benefit specific populations who may otherwise find it challenging to access services or who wish to remain anonymous.

Using the Concept of Health Literacy to Understand How People Living with Motor Neurone Disease and Carers Engage in Healthcare: A Longitudinal Qualitative Study

The growing body of information-seeking and decision-making literature in motor neurone disease (MND) has not yet explored the impact of health literacy. Health literacy relates to the skills people have to access, understand, and use health information and is influenced by motivation to engage with healthcare. We aimed to better understand how people affected by MND engage in healthcare by examining longitudinal interview data using the construct of health literacy. Semi-structured interviews were conducted with 19 persons living with MND and 15 carers recruited from a specialist MND clinic using maximum variation sampling. Transcripts were deductively coded using a framework of health literacy behaviours. The analysis used a matrix-based approach for thematic analysis of longitudinal data. People living with MND and carers sought nuanced information dependent on their priorities and attitudes. Information uptake was influenced by perceived relevancy and changed over time. Time allowed opportunity to reflect on and understand the significance of information provided. The findings indicate that persons living with MND and carers benefit when information and consultations are adapted to meet their communication needs. The results highlight the potential benefits of gaining an early understanding of and accommodating the communication needs, personal preferences, and emotional readiness for information for persons living with MND and their carers.