Comfort experience in palliative care: a phenomenological study

Lived Experiences of Physiotherapists in Caring for People with Advanced Amyotrophic Lateral Sclerosis in Portugal: A Phenomenological Study

Amyotrophic lateral sclerosis (ALS) is a disease that has a multidimensional impact on a person's life, with symptoms associated with a significant loss of autonomy. Specialized palliative care (PC) should be provided early and throughout the course of the disease. Indeed, physiotherapists should be understood as integral members of the multidisciplinary team in PC, in the care and improvement of the quality of life of these people. This study aimed to describe the lived experience of physiotherapists in the context of intervention in people with advanced ALS and their families. Descriptive phenomenology was employed as a framework for conducting semi-structured interviews to reveal experiences. Sixteen physiotherapists who performed interventions on at least one person with advanced ALS in the last 2 years were included in the study. The study involved conducting semi-structured individual interviews, through the Zoom® videoconferencing platform (version 6.4.3). Data were analyzed according to Giorgi's five-stage approach and managed using webQDA software (Version 3.0, University of Aveiro, Aveiro, Portugal). The COREQ checklist was applied in the study. Participants were mostly female (n = 12) and aged between 26 and 55 years (M = 36.81; SD = 6.75). Four constituents were identified: (1) undulating course of a complex disease; (2) barriers to person-centered care; (3) enablers of person-centered care; (4) transition between curative and palliative care. The findings illustrate the multidimensional impact of the disease trajectory on the person and their family. This study highlights the need to invest in specialized training for physiotherapists, contributing to a person-centered PC practice with an impact on promoting comfort and quality of life.

On comfort in palliative care

ABSTRACTComfort is a central aspect of palliative care, encompassing the management of pain and symptoms, as well as how people feel and experience care. Comfort has been argued to be especially tenuous or transient in palliative care, as a constantly shifting set of bodily sensations and relations are anticipated and cared for. In this article, drawing on in-depth interviews and photo elicitation, we explore the accounts of patients, family carers, staff and volunteers from a palliative care service in Australia, to understand how care is configured and facilitated through everyday gestures of comfort. We unpack how comfort (and comforting) is understood, sought, and done, to reveal how it is experienced as a set of social, relational, processual, and dynamic relations between bodies and environments. Our findings reveal how comfort for those nearing the end of life and those who care for them is brought about variously in the familiarity and reliability of things and surroundings, as well as through gestures of intimacy, recognition, and flexibility. We find that while predominantly considered as intentional and momentary, comfort has lasting effects. These lingering affective resonances, we argue, are key to recognising the diversity of what matters to people in palliative care.

Knowledge and attitude of nursing students regarding pediatric palliative care in a teaching nursing institute

BACKGROUND

According to the World Health Organization, palliative care (PC) for children involves actively caring for the child's health, mind, and spirit and supporting the family. Pediatric palliative care (PPC) is characterized as a comprehensive strategy for both the child with a fatal illness and his or her family during their tragedy. The study aims to assess nursing students' knowledge and attitudes regarding PPC and determine the association with selected sociodemographic variables.

MATERIALS AND METHODS

This descriptive (cross-sectional observational) study was carried out by SUM Nursing College, Bhubaneswar from November 2022 to October 2023 by using three tools (a self-structured questionnaire on sociodemographic data, a standardized questionnaire on knowledge, and a standardized questionnaire on attitude) to assess the level of knowledge and attitude among study participants toward PPC. Nursing students who have already been exposed to pediatric subjects such as B.Sc. 3rd and 4th year, GNM 2nd and 3rd year, and all nursing students of post basic B.Sc, and M.Sc., were included in the study.

RESULT

Based on the investigation, it was discovered that among 223 of the total study sample, 39.5% had good knowledge, and the remaining 60.5% had poor knowledge. In addition, when the attitude of nursing students was analyzed, it was found that 54.3% of the total study sample had positive attitudes, and the remaining 45.7% had negative attitudes toward PPC.

CONCLUSION

As nurses play a major role in delivering PPC, it could be included as a mandatory part in their educational curriculum. A similar study can be replicated among other healthcare professionals in several areas regarding PPC.

Knowledge and attitude of nursing students regarding pediatric palliative care in a teaching nursing institute

Background:

According to the World Health Organization, palliative care (PC) for children involves actively caring for the child’s health, mind, and spirit and supporting the family. Pediatric palliative care (PPC) is characterized as a comprehensive strategy for both the child with a fatal illness and his or her family during their tragedy. The study aims to assess nursing students’ knowledge and attitudes regarding PPC and determine the association with selected sociodemographic variables.

Materials and Methods:

This descriptive (cross-sectional observational) study was carried out by SUM Nursing College, Bhubaneswar from November 2022 to October 2023 by using three tools (a self-structured questionnaire on sociodemographic data, a standardized questionnaire on knowledge, and a standardized questionnaire on attitude) to assess the level of knowledge and attitude among study participants toward PPC. Nursing students who have already been exposed to pediatric subjects such as B.Sc. 3rd and 4th year, GNM 2nd and 3rd year, and all nursing students of post basic B.Sc, and M.Sc., were included in the study.

Result:

Based on the investigation, it was discovered that among 223 of the total study sample, 39.5% had good knowledge, and the remaining 60.5% had poor knowledge. In addition, when the attitude of nursing students was analyzed, it was found that 54.3% of the total study sample had positive attitudes, and the remaining 45.7% had negative attitudes toward PPC.

Conclusion:

As nurses play a major role in delivering PPC, it could be included as a mandatory part in their educational curriculum. A similar study can be replicated among other healthcare professionals in several areas regarding PPC.

Applying Comfort Theory to Improve Outcomes for People in Sickle Cell Crisis

When people with sickle cell disease in vaso-occlusive crisis need hospitalization, they often experience fragmented and disparate treatment. Racial, gender, and socioeconomic treatment bias by providers, including nurses, is complicated by the current reactionary United States (US) controlled substance policies. To provide high-quality and respectful care, nurses can use Kolcaba's Comfort Theory as the framework for a holistic plan to assess, deliver individualized interventions, and evaluate outcomes for people experiencing vaso-occlusive crisis. Once in the electronic medical record, it can guide care during future hospitalizations. By refocusing on the nursing value of providing comfort care to individuals in distress, nurses can change treatment outcomes for clients.

Comfort Level of Patients Undergoing Hemodialysis and Associated Factors in Turkey: A Cross-Sectional Study

BACKGROUND

Hemodialysis is one of the treatment methods for chronic kidney disease, which is a common disease around the world. The problems that occur during the hemodialysis process may cause discomfort in patients. Therefore, it is important to regularly evaluate the concept of comfort in hemodialysis patients.

AIM

To determine the comfort level of patients undergoing hemodialysis and the associated factors.

METHODS

This study was a descriptive cross-sectional study conducted among 95 patients who had been undergoing hemodialysis for at least 6 months. Data were collected using the sociodemographic characteristics form and the Hemodialysis Comfort Scale (HDCS).

RESULTS

The mean age of the participants was 58.37 ± 16.62 years. The median duration of hemodialysis was 5 (1-25) years. A total of 51% of the patients were male, 54.7% were married, 34.7% had completed primary school, and 85.3% had a comorbid chronic disease. The mean hemodialysis comfort score was 23.85 ± 6.93. The mean score was significantly higher in male patients (P = 0.041) and those without comorbid chronic disease (P = 0.013). There was a significant negative correlation between the age of hemodialysis patients and the mean hemodialysis comfort score (r = -0.260, P = 0.011).

CONCLUSION

The comfort level was significantly better in hemodialysis patients who were male, those without comorbid disease, and those who were younger. There is a need to periodically assess the comfort level of hemodialysis patients and intervene when necessary in order to improve their quality of life.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care

BACKGROUND

Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted.

AIM

The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care.

DESIGN

A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews.

DATA SOURCES

Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care.

RESULTS

A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature.

CONCLUSIONS

This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary Narrative Inquiry

Objective

Patient-centered care calls to contain patients in their time of crisis. This study extends the knowledge of provider patient interactions in the hectic environment of acute care applying Bion's container-contained framework from psychoanalysis.

Methods

Following ethical approval, we performed a narrative inquiry of the experiences of ten patients upon discharge from lengthy hospitalizations in acute care. Interviews were conducted upon discharge and about one-month post-discharge.

Findings

Data analysis suggests four modes of containing of patients by providers. In nurturing interactions, typical of an active container-contained mode, patients experienced humanized care, symptom control, hope, and internal locus of control. This mode yielded patient gratitude toward providers, wellbeing, and post-discharge self-management of diseases. In rigid and wall-free modes of containing, patients experienced a sense of powerlessness and discomfort. A new mode of container-contained was identified, the “Inverted Container”, which extends Bion's theory and contradicts patient-centered care. In inverted containers, patients contained the providers yet reported feeling gratitude toward providers. The gratitude constitutes a defense mechanism and reflects a traumatic experience during hospitalization, which led to post-discharge distrust in providers and hospitals and poor self-management of illness.

Conclusions

To effectively provide patient-centered care, provider-patient interaction in lengthy hospitalizations must move along a clinical axis and a relationship axis. This shifting may facilitate containing patients in their time of crisis so essential processes of reflection, projection, and transference are facilitated in-hospital care.

Monitoring and Management of the Palliative Care Patient Symptoms: A Best Practice Implementation Project

Background: In palliative care, symptoms are multiple and combined, evolving and changing, with a multidimensional character and multifactorial causes, and a high prevalence, negatively influencing the patient’s and family’s quality of life. Nurses who provide palliative care need to recognize and respond effectively to their patients’ symptoms. Methods: A project will be applied to implement the best practice in monitoring and managing palliative care patients’ symptoms. The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit and feedback tool will be used. The JBI PACES and GRiP framework for promoting evidence-based healthcare involves three phases of activity. First, a baseline audit. In a second phase, feedback will be given to the project team after the conclusion of the baseline audit report. Then, a third phase will be conducted as a follow-up audit. Conclusions: This project will improve the practice of the nursing team in monitoring and managing the symptoms of palliative care patients, positively influencing the quality of life of the patient and his family. The implementation and dissemination of this project could boost its replication in other centres.

“Keeping the Light On”: A Qualitative Study on Hope Perceptions at the End of Life in Portuguese Family Dyads

Hope performs an important role in how patients and their families cope with suffering and stressful events. To better inform practice and theory on hope, palliative care research should include both patients and their family carers, given their strong interdependence. The aim of this study was to explore how hope is experienced in dyads formed by end-of-life patients and their family carers. In this qualitative study, data were collected by in-depth interviews with seven Portuguese family dyads. Analysis followed a thematic analysis approach. The analysis of the interviews shed light on the importance of hope for all participants, and the challenges involved. Family dyads noted several barriers and facilitators to perceptions of hope. Barriers to hope included limitations imposed by illness, feelings of anguish and helplessness, and poor communication with clinicians. Hope facilitators included supportive others, positive thinking and sense of humour, connection with nature, faith in religion and science, and a sense of compassion with others and altruism. Given the multidimensional scope of hope, the main challenge for family dyads is to look beyond the disease itself. Thus, palliative care teams should be encouraged to support and foster realistic hope, helping families prepare for death, in the context of advanced cancer.

The meaning of comfort measures only order sets for hospital-based palliative care providers

Purpose

Comfort Measures Only (CMO) is a label commonly used in the USA that guides the care of a hospitalized patient who is likely to die. The CMO label has unclear and inconsistent meaning, calling to question the experiences and practices of hospital-basedalliative care providers. The purpose of this study was to understand the meaning of CMO as experienced by hospital-based palliative care providers.

Methods

Using hermeneutic phenomenological research, we investigated eight palliative care experts’ common experiences and shared practices of using CMO order sets in their hospital work settings. Data were collected through individual face-to-face interviews, and were analysed by an interpretive team.

Results

Four related themes and one constitutive pattern of “Dealing with Dying” reflect the meaning of comfort-measures-only practices. The themes are: comfort care as morphine drip; enacting a traditional binary pattern of care: all or nothing; supporting patient and family at end of life vs. CMO; and evolving culture—a better way to care for the dying.

Conclusion

Palliative care providers and non-palliative clinicians understood and practiced end of life care in sharply different ways with dying in hospital settings, raising new questions that analyse, modify and extend extant knowledge.

A conceptual analysis of the meaning of comfort at the end-of-life using the Walker and Avant (2014) Framework

Objective

The aim of the authors is to clarify the concept of comfort at the end-of-life in order to support understandings of fundamental nursing care needed at this stage of healthcare.

Methods

The Walker and Avant framework was applied to develop a deeper understanding of the concept of comfort at the end of life.

Results

Five defining attributes of comfort in the end-of-life were identified and they are having a peaceful home-life environment, trust and consolation, proximity and social-cultural support, alleviation of suffering, and a process of integrated intervention by nurses.

Conclusions

At the end-of-life patients commonly experience physical, psychological, social-cultural, and environmental discomfort. Patients’ families also encounter significant challenges. However, their comfort needs are often secondary to that of the patient. Additionally, a lack of clarity exists regarding the holistic meaning of comfort at the end-of-life, which can largely be confined to understandings of physical comfort for the patient, with a limited understanding of addressing family/caregivers’ needs. Therefore, this concept analysis may provide some guidance in this regard and also provides support toward a more integrated understanding of the concept.

An integrative review to identify how nurses practicing in inpatient specialist palliative care units uphold the values of nursing

Background

Caring for individuals and their families with a life-limiting, symptomatic illness and those who are dying has long been an integral role of palliative care nurses. Yet, over the last two decades, the specialty of palliative care has undergone significant changes in technology and medical treatments which have altered both the disease trajectory and the delivery of palliative care. To date, there is little evidence as to the impact of these medical and nursing advancements on the role of nurses working in palliative care and how in clinical practice these nurses continue to uphold their nursing values and the philosophy of palliative care.

Methods

An integrative review was conducted searching seven academic databases from the time period of January 2010 – December 2019 for studies identifying research relating to the role of the palliative care nurse working in specialist palliative care units and hospices. Research articles identified were screened against the inclusion criteria. Data extraction was completed on all included studies and the Crowe Critical Appraisal Tool was utilized to appraise the methodological quality and thematic analysis was performed guided by Braun and Clarke’s framework. The review was conducted and reported in lines with PRISMA guidelines.

Results

The search yielded 22,828 articles of which 7 were included for appraisal and review. Four themes were identified: (1) enhancing patient-centred care (2) being there (3) exposure to suffering and death (4) nursing values seen but not heard. The findings highlight that while palliative care nurses do not articulate their nurse values, their actions and behaviors evident within the literature demonstrate care, compassion, and commitment.

Conclusion

These findings suggest that there is a need for nurses working in specialist palliative care units to articulate, document, and audit how they incorporate the values of nursing into their practice. This is pivotal not only for the future of palliative nursing within hospice and specialist palliative care units but also to the future of palliative care itself. To make visible the values of nursing further practice-based education and research is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00810-6.

Total pain and comfort theory: implications in the care to patients in oncology palliative care

ABSTRACT Objective: To reflect on the possible connections between Katharine Kolcaba's Theory of Comfort and Cicely Saunders’s concept of Total Pain and the implications to the care of the oncology palliative care patient. Method: Theoretical reflection based on a literature review carried out in May 2020, in the PubMed and LILACS databases, which sought to answer the question: “Are there any theoretical-conceptual connections between Kolcaba's Theory of Comfort and the concept of Total Pain by Saunders?” Results: The knowledge of the concepts presented allows redirecting the focus of care towards individualized actions to strengthen the patient and his participation in the choices of comfort interventions. Conclusion: Understanding the connections between the concept and theory presented provides the patient in oncology palliative care with individualized and qualified care, focused on the person and not on the disease and can contribute to a greater effectiveness of nursing interventions aimed at the relief of suffering.

Qualitative study to explore what patients with heart failure find significant during integrated palliative care sessions in a Danish clinic

OBJECTIVE

In the field of palliative care (PC) as it is integrated into heart failure (HF) treatment, it is essential to explore the patient experience and build on this knowledge for the further development of PC practice and policy. Based on an intervention study, this paper explores what patients with HF find significant in integrated sessions using a narrative S' approach.

DESIGN

We conducted a semistructured interview study with a qualitative analysis focused on meaning making. The study follows the guidelines of Consolidated Criteria for Reporting Qualitative Research.

PARTICIPANTS AND SETTING

The inclusion criteria for the PC intervention were (1) a new diagnosis of HF, (2) follow-up treatment at this local Danish HF clinic and (3) informed consent to participate in the integrated PC intervention. The only exclusion criterion was if the patient was already engaged in a PC programme. 20 patients agreed to participate in the intervention, and 12 of these completed the S' approach sessions and participated in this interview study.

RESULTS

Overall, the analysis showed that the integrated S' approach sessions were successful in joining an embodied patient perspective with a medical perspective. The thematic analysis resulted in three themes supporting the overall findings: sessions bring comfort, telling your story provides a sense of meaningfulness, and integrating perspectives of HF into everyday life.

CONCLUSION

The method using the S' approach in integrated PC and HF sessions was significant in various ways. First, patients experienced a calm and safe atmosphere and perceived that the nurse was truly interested in them. Second, the integrated sessions based on the S' approach were able to bring comfort to lived physical, psychosocial and existential issues. Last, it allowed patients to combine their embodied understanding of HF with a medical perspective, thereby finding meaning in the sense of how everything is connected.

Nursing diagnoses clusters: survival and comfort in oncology end-of-life care

BACKGROUND

Holistic care and nursing diagnoses are essential in end-of-life, since interventions based on these ensure greater patient comfort and quality of life.

AIMS

To identify clusters of nursing diagnoses and repercussions for patient comfort and survival.

METHODS

A prospective cohort of 66 end-of-life patients with cancer was examined. Diagnostic groupings were created based on the Kolcaba's theory of comfort. Pearson's chi-square test and Kaplan-Meier estimator were used to assess the relationship between clusters, comfort, and survival.

FINDINGS

Three diagnostic groups and 23 nurse diagnoses were used. The first and most prevalent diagnosis cluster was related to intestinal tract disorders and sleep. The second was related to neuropsychological characteristics and fatigue associated with lower survival, while the third cluster was related to functionality and perception, which was shown to be associated with less comfort.

CONCLUSION

The three clusters were significantly associated with comfort and survival.

Maximising comfort: how do patients describe the care that matters? A two-stage qualitative descriptive study to develop a quality improvement framework for comfort-related care in inpatient settings

OBJECTIVE

To develop a multidimensional framework representing patients' perspectives on comfort to guide practice and quality initiatives aimed at improving patients' experiences of care.

DESIGN

Two-stage qualitative descriptive study design. Findings from a previously published synthesis of 62 studies (stage 1) informed data collection and analysis of 25 semistructured interviews (stage 2) exploring patients' perspectives of comfort in an acute care setting.

SETTING

Cardiac surgical unit in New Zealand.

PARTICIPANTS

Culturally diverse patients in hospital undergoing heart surgery.

MAIN OUTCOMES

A definition of comfort. The Comfort ALways Matters (CALM) framework describing factors influencing comfort.

RESULTS

Comfort is transient and multidimensional and, as defined by patients, incorporates more than the absence of pain. Factors influencing comfort were synthesised into 10 themes within four inter-related layers: patients' personal (often private) strategies; the unique role of family; staff actions and behaviours; and factors within the clinical environment.

CONCLUSIONS

These findings provide new insights into what comfort means to patients, the care required to promote their comfort and the reasons for which doing so is important. We have developed a definition of comfort and the CALM framework, which can be used by healthcare leaders and clinicians to guide practice and quality initiatives aimed at maximising comfort and minimising distress. These findings appear applicable to a range of inpatient populations. A focus on comfort by individuals is crucial, but leadership will be essential for driving the changes needed to reduce unwarranted variability in care that affects comfort.

Striving for a balance between leading and following the patient and family - nurses' strategies to facilitate the transition from life-prolonging care to palliative care: an interview study

Background

The transition from life-prolonging to palliative care (PC) can be challenging often characterized by psychical, physiological, social and existential changes. Knowledge of how to support the patient and family in this specific care phase is lacking, and this area needs to be further explored. The aim of this study was to investigate strategies that registered nurses (RNs) use to ease the transition from life-prolonging care to PC for patients with incurable disease.

Methods

The study has a descriptive design. Fourteen RNs working in a specialized PC unit were interviewed. The data were analysed using content analysis.

Results

The RNs’ strategies can be described under the categories “Getting to know the patient and creating a relationship”, “Providing support”, “Adapting to individuals’ needs” and “Enabling conversations”.

Conclusion

The findings show that the RNs in this population used strategies that not only took time but also required knowledge about the transition process and required the ability to identify and meet patients’ and families’ unique needs. Patients’ difficult and exposed situation needs to be addressed through a structured follow-up after informing about the change from life-prolonging care to PC. RNs have a unique role of supporting both the patient and the family in the transition from life-prolonging care to PC for patients with incurable disease.