The experience of caring for patients at the end-of-life stage in non-palliative care settings: a qualitative study

Self-reported knowledge and difficulties towards palliative care among healthcare professionals in rural China: a cross-sectional study

BACKGROUND

Palliative care (PC) in rural China remains underdeveloped, with limited specialized services and significant challenges for healthcare professionals. This study aimed to examine the difficulties in providing PC and their factors from the perspective of healthcare professionals in rural Henan province, China, where specific PC services are currently unavailable.

METHODS

A cross-sectional study was conducted between June and July 2024, using a convenience sample of 255 healthcare professionals from four secondary/tertiary hospitals participated. Data were collected on participants' demographic characteristics, information on recently deceased cancer patients they had cared for, and PC-related information. PC knowledge and PC difficulties were assessed using the Palliative Care Knowledge Questionnaire-Chinese version (PCKQ-PCN) and the Palliative Care Difficulties Scale (PCDS). Linear regression analysis identified factors associated with PC difficulties.

RESULTS

Among the 255 participants (Mean[age]: 34.82 ± 7.04), 71.8% were females, 57.3% were physicians, and the average work experience was 10.20 years. Regarding PC experience, 48.2% had participated in 1-2 training sessions annually over the past two years, and 32.2% reported a poor understanding of PC. The total PCKQ-PCN mean score was 13.28 ± 2.62, with 25.2% of participants classified as having poor knowledge. The PCDS mean score was 42.58 ± 13.59. Linear regression analysis showed that participating in at least one PC training session every six months (β = -10.66; p = 0.032), having experience caring for seriously ill people at home (β =  -6.31; p = 0.024), greater knowledge of symptom management (β = -3.72; p = 0.012), and higher levels of basic knowledge (β = -5.12; p = 0.007) were negatively associated with PC difficulties. Conversely, limited understanding of PC (β = 12.95; p = 0.021), greater knowledge of spiritual care and death education (β = 4.95; p = 0.034), and having new rural cooperative medical insurance (β = 6.36; p = 0.023; β = 3.21; p = 0.042) were positively associated with PC difficulties.

CONCLUSIONS

This study highlights critical gaps in rural China's PC services, including inadequate training, limited focus on spiritual needs and death education, and disparities in insurance coverage. Targeted training programs in healthcare professionals and policy reforms are urgently needed to improve PC quality and accessibility in rural areas.

Motivations behind end-of-life care: a qualitative study of Iranian nurses' experiences

BACKGROUND

Providing high-quality end-of-life care is currently a paramount health priority. Given that the standard of care is intrinsically linked to nurses' motivations, it is becoming too imperative to explore the contributing factors Consequently, this study was undertaken to elucidate the experiences of Iranian nurses regarding their motivation for delivering end-of-life care.

METHODS

This research is a qualitative, descriptive inquiry employing conventional content analysis, carried out at two governmental hospitals in Gorgan, northern Iran, from February to July 2023. 12 nurses were purposefully selected to participate in the study, ensuring maximal diversity. The data were collected through semi structured interviews and analyzed using Graneheim and Lundman's five-step method. The coding process was facilitated by the useof MAXQDA version 10 software. To establish rigor, the four criteria outlined by Guba and Lincoln were applied.

RESULTS

the participants included eight women and four men with an average age of 39.6 ± 6.31 years. The data analysis yielded five main categories and fifteen subcategories. The main categories were: "The Foundations of professional care in nursing", "Core Drivers in Optimal End-of-Life Care", "Family Involvement in End-of-Life Care", "Incorporating Spiritualism in Care" and "Dominant motivational Issues Within the Caregiving Atmosphere".

CONCLUSIONS

This study delineates the experiences that influence the provision of end-of-life care from the perspective of Iranian nurses. Innate traits such as empathy and a passion for nursing, in addition to nurses' moral compass and spiritual beliefs, serve as pivotal motivational stimuli. Leveraging these findings can be instrumental in shaping healthcare practices and policies to enhance the quality of end-of-life care.

Nurses' adherence to ethical principles - A qualitative study

BACKGROUND

Nursing is regulated by a set of professional standards. Whilst many forms of ethics apply to nursing, the biomedical ethical framework is common, involving autonomy, beneficence, non-maleficence and justice. In healthcare, nurses often encounter ethical dilemmas that require them to navigate conflicting ethical principles. However, how nurses adhere to these principles in such situations is unclear.

RESEARCH AIM

To explore how registered nurses adhere to ethical principles when dealing with ethical dilemmas at work.

RESEARCH DESIGN

A qualitative descriptive study design.

PARTICIPANTS AND RESEARCH CONTEXT

Between August and December 2023, 21 registered nurses were recruited from a teaching hospital through purposive sampling. Data were collected through semi-structured in-person interviews or online video conferencing. Braun and Clarke's thematic analysis approach was employed to analyse the data.

ETHICAL CONSIDERATIONS

Interview participation was voluntary. Written consent was obtained before participation. Participants' real identities were replaced with pseudonyms. This study was approved by the SingHealth Centralised Institutional Review Board.

FINDINGS

The data analysis developed four major themes and 15 subthemes. The four major themes are "Addressing the dilemma," "Contemplating the principles and consequences," "Coordinating for well-informed, ethical decision," and "Self-reflecting and finding consolation."

CONCLUSION

This study explains how nurses navigate and uphold ethical principles when caring for patients to the best of their ability. Fully adhering to ethical principles can be challenging for caring for actively dying patients. Further research can expound on nurses' experiences and adherence to ethical principles in complex clinical cases.

What we learnt from parents' death experience: A cross-sectional study of death literacy and parent's death quality among adult children in China

OBJECTIVES

This study aims at investigating the current status of death literacy and parent's death quality among adult children in China. A cross-sectional survey was conducted to explore the associations between death literacy and parent's death quality and to provide evidence for developing public policies for improving the quality of death and end-of-life care for the population in the Greater Bay Area (GBA) of China.

METHODS

A cross-sectional design was adopted. Participants who experienced their father's and/or mother's death were recruited from 5 cities in the GBA of China in 2022. The Good Death Inventory (GDI) and the Death Literacy Index (DLI) were used to investigate the perceived quality of death of the parents of the participants and the death literacy of the participants.

RESULTS

A total of 511 participants were recruited. Participants with higher GDI scores were positively associated with DLI scores (p < 0.001). Adult children who had close relationships before their parents' death also had higher levels of DLI.

SIGNIFICANCE OF RESULTS

This study investigated death literacy among bereaved adult children in China, filling a gap in the investigation of death literacy among Chinese residents. It found that parents' death experience can have a significant impact on the death literacy of adult children, which may affect their understanding and preparation for their own eventual death. Promotion of family discussion on death, development of community palliative care, and improving public death literacy are urgently needed in China.

The systemic challenges of non-palliative care professionals caring for end-of-life patients: A lived experience study

OBJECTIVES

The aims of this study are to identify the challenges faced by non-palliative care professionals (NPCPs) in caring for end-of-life patients; determine how these challenges interact with and influence each other systemically; and advance the theories and practices for supporting NPCPs in the provision of quality end-of-life care beyond the boundaries of palliative medicine.

METHODS

A constructivist phenomenological research design with an Interpretive-Systemic Framework of inquiry was adopted. Thirty-five physicians, 35 nurses, and 35 Medical Social Workers who play critical roles in caring for end-of-life patients and belonging to the 9 major medical disciplines of Cardiology, Geriatric, Intensive Care Medicine, Internal Medicine, Nephrology, Neurology, Oncology, Respiratory Medicine, and Surgery were recruited through purposive snowball sampling from 3 major public hospitals.

RESULTS

Framework analysis revealed 5 themes and 17 subthemes that illuminate the individual, relational, cultural, institutional, and structural challenges that NPCPs faced in rendering end-of-life care. These challenges influence each other within the health-care ecosystem, serving to perpetuate or heighten care obstacles.

SIGNIFICANCE OF RESULTS

This is the first known study exploring the systemic challenges of NPCPs spanning 9 major medical disciplines and encompassing 3 professional stakeholders responsible for the care for end-of-life patients, thus ensuring perspective inclusivity across the health-care system. Recommendations that consider the complexity of the interactions between these systemic challenges are presented in detail.

Development and Psychometric Evaluation of the End-of-Life Nursing Competency Scale for Clinical Nurses

This study aimed to develop and establish psychometric properties of the End-of-Life Nursing Competency Scale for Clinical Nurses. The initial items were derived from an in-depth literature review and field interviews. The content validation of these items was assessed over three rounds by experts in end-of-life nursing care. The study included 437 clinical nurses from four hospitals in S, E, and D cities in South Korea. The final exploratory factor analysis resulted in a scale consisting of 21 items with the following five factors that explained 68.44% of the total variance: Physical care-imminent end-of-life, legal and administrative processes, psychological care-patient and family, psychological care-nurses' self, and ethical nursing. The final model with these five subscales was validated through confirmatory factor analysis. Both item convergent-discriminant validity and known-group validity, which compared two groups based on clinical experience (p < 0.008) and working department (p < 0.008), were satisfactory. The internal consistency, as measured by Cronbach's α, ranged from 0.62 to 0.89 for the subscales and was 0.91 for the total scale. This scale has been validated as a reliable and effective instrument for clinical nurses to self-assess their end-of-life nursing competencies in a clinical setting.

Barriers Faced by Healthcare Providers during Home Visits of Palliative Care Patients - A Qualitative Study

Objectives

We, the Department of Community Medicine, have been training healthcare providers for palliative care in the hospital and community setting. There were many difficulties in providing proper palliative care. The objective is to explore the various difficulties faced by Junior Residents, auxiliary nurse and midwife (ANM) and medical social workers (MSWs) during the home visits of palliative care patients and to address those difficulties in future visits.

Materials and Methods

The study was conducted in our peripheral institutions such as the Rural Health Training Centre and the Urban Health Training Centre among Junior Residents, ANMs and MSWs who had provided palliative care for the patients. Qualitative study design includes participatory research action techniques such as force field analysis, cobweb diagram, and pairwise ranking, and Systematic techniques include the Delphi technique.

Results

Indicators for difficulties faced by Junior Residents were derived and plotted based on priorities and joined to form a cobweb diagram. Difficulties were time constraints, lack of resources such as medications and transport facilities, need for specialist care, and non-adherence to the advice. Driving force and restraining force for palliative care were derived and plotted on the force field analysis. The favourable factors in providing palliative care services of the healthcare providers are self-satisfaction with treating the patient, satisfaction due to treatment at the doorstep, understanding the patient's psychological or social factors affecting their health, skill development and counselling of the patient. The restraining factors in providing palliative care services of the healthcare providers are time constraints, lack of resources, patient not following the advice properly, improper care by caregivers and unable to fulfill certain needs of the patient. Pairwise scoring/ranking was done for MSWs by plotting the issues faced in palliative care visits in rows and columns. The difficulties were time constraints, lack of resources, lack of proper knowledge of staff and need for specialist care. The possible potential solutions derived from the Delphi technique were proper planning to reduce time constraints and intense counseling of patients on adherence to treatment.

Conclusion

It helped to identify the difficulties faced by healthcare providers and to plan for solutions in future palliative home care visits.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Chinese American Patients

The Chinese American population is one of the fastest-growing communities in the United States, composed of ∼5.4 million people, and represents ∼5.5% of overseas Chinese populations. With an expected exponential population rise, Chinese American patients who experience serious illness or approach end-of-life (EOL) may find their cultural values influencing the medical care they receive. Palliative care clinicians must recognize diverse cultural beliefs and preferences of Chinese American patients and their families. In this study, we provide 10 cultural pearls to guide the provision of palliative and EOL care for Chinese American patients, including discussions of Chinese traditions, communication strategies for Chinese patients and families, advance care planning, and EOL care beliefs.

Psychometric Properties of the Knowledge, Attitude, and Practice Behavior of Oncology Nurses on Advance Care Planning Instrument

OBJECTIVE

Advance care planning has been practiced in Western countries for several years, but non-Western cultures face challenges in implementation. This study was dedicated to translating the instrument measure into Chinese, examining its psychometric qualities and exploring the relationships among knowledge, attitudes, and practicing behaviors in advance care planning among oncology nurses in China.

DATA SOURCES

The research adopted a cross-sectional design from September 3 to October 5, 2021. After translation and cultural adaptation, oncology nurses (N = 249) were involved. The research used psychometric evaluation to verify that the content validity, structural validity, internal consistency, and test-retest reliability enhanced the analytical rigorous instrument.

CONCLUSION

The translated and adapted instruments showed reasonable psychometric properties. The Chinese version of the KAB-ACP for oncology nurses is a consistent, valid, and reliable instrument for assessing knowledge, attitude, and practice behavior of Chinese-speaking nurses who work in advance care planning by researchers or clinicians.

IMPLICATIONS FOR NURSING PRACTICE

Measures of oncology nurses' knowledge, attitudes, and practice behaviors will allow for more targeted interventions that will improve end-of-life care outcomes.

Critical Care Nurses' Perceptions of Clinical Alarm Management on Nursing Practice

The alarm management of physiological monitoring systems is a key responsibility of critical care nurses. However, the high numbers of false and nonactionable (true but clinically irrelevant) alarms cause distractions to healthcare professionals, interruptions to nursing workflow, and ignoring of crucial tasks. Therefore, understanding how nurses manage large amounts of alarms in their daily work could provide a direction to design interventions to prevent adverse patient care effects. A qualitative design with focus group interviews was conducted with 37 nurses in Taiwan. Content analysis was performed to analyze the interview data, and four main themes were derived: (1) the foundation stone of critical care nursing practice; (2) a trajectory adaptation of alarms management; (3) adverse impacts on the quality of care and patient safety; and (4) a hope for multimodal learning alternatives and wireless technology. Nurses manage alarm parameter settings influenced not only by their knowledge and skills of patient care, but also in accordance with the three dimensions of technology, human, and organization evaluation framework. Customized alarm management training alternatives, patient-centered care values, and application of wireless technology are the suggested approaches to enhance nursing care and minimize the risk of adverse events.

Predictors of end-of-life care stress, calling, and resilience on end-of-life care performance: a descriptive correlational study

Background

Prolonging the end-of-life process means that the duration of health care work increases and the management of death is delegated to health care providers by patients’ families. Thus, it is important to explore measures to enhance the quality of end-of-life care by identifying the predictors thereof. End-of-life care should be people-centred, relieving serious health-related suffering, be it physical, psychological, social, or spiritual. Nurses who provide end-of-life care usually spend the most time with dying patients, administering care to help patients who wish to die with dignity; therefore, end-of-life nursing care is highly significant.

Methods

This study was conducted on nurses of 500-bed or larger university hospitals in city D and province C in South Korea from 20 August to 10 September 2020 using a structured questionnaire. A total of 213 nurses with a minimum clinical career of one year and at least one EOLC experience participated. The final analysis sample consisted of 206 nurses. Descriptive analysis, Pearson’s correlation coefficients, ANOVA, t-test, and multiple-regression analysis were used to analyse the data.

Results

This study found that end-of-life care performance was significantly positively correlated with end-of-life care stress [r = .253, p < .001], sense of calling [r = .424, p < .001], and resilience [r = .397, p < .001]. End-of-life care stress [β = .185, p = .003], sense of calling [β = .259, p < .001], resilience [β = .252, p < .001], and working in a hospice ward [β = .140, p = .041] or intensive care unit [β = .218, p = .008], as opposed to the emergency department, were identified as predictors of end-of-life care performance. These factors explained 28.3% of the variance in the end-of-life care performance in this study.

Conclusions

Boosting the sense of calling and resilience among nurses providing palliative care can improve overall end-of-life care performances. Subsequent studies should develop and evaluate interventions and programs that could improve these factors to ensure a positive change in health care and enhance the quality of end-of-life care in hospitals.

Prognostic decision-making about imminent death within multidisciplinary teams: a scoping review

OBJECTIVE

To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients.

DESIGN

Scoping review.

SETTING

Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings.

DATA SOURCES

The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients.

RESULTS

40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers.

CONCLUSIONS

Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.

Identifying Core Domains to Assess the "Quality of Death": A Scoping Review

CONTEXT

There is growing recognition of the value to patients, families, society, and health systems in providing healthcare, including end-of-life care, that is consistent with both patient preferences and clinical guidelines.

OBJECTIVES

Identify the core domains and subdomains that can be used to evaluate the performance of end-of-life care within and across health systems.

METHODS

PubMed/MEDLINE (NCBI), PsycINFO (ProQuest), and CINAHL (EBSCO) databases were searched for peer-reviewed journal articles published prior to February 22, 2020. The SPIDER tool was used to determine search terms. A priori criteria were followed with independent review to identify relevant articles.

RESULTS

A total of 309 eligible articles were identified out of 2728 discrete results. The articles represent perspectives from the broader health system (11), patients (70), family and informal caregivers (65), healthcare professionals (43), multiple viewpoints (110), and others (10). The most common condition of focus was cancer (103) and the majority (245) of the studies concentrated on high-income country contexts. The review identified five domains and 11 subdomains focused on structural factors relevant to end-of-life care at the broader health system level, and two domains and 22 subdomains focused on experiential aspects of end-of-life care from the patient and family perspectives. The structural health system domains were: 1) stewardship and governance, 2) resource generation, 3) financing and financial protection, 4) service provision, and 5) access to care. The experiential domains were: 1) quality of care, and 2) quality of communication.

CONCLUSION

The review affirms the need for a people-centered approach to managing the delicate process and period of accepting and preparing for the end of life. The identified structural and experiential factors pertinent to the "quality of death" will prove invaluable for future efforts aimed to quantify health system performance in the end-of-life period.

The decision for hospice care in patients with terminal illness in Shanghai: A mixed-method study

Objectives

To investigate why patients with terminal illness and their families in Shanghai choose the hospice ward and their decision-making process.

Methods

This was a mixed-method study consisting of a cross-sectional survey and a descriptive qualitative study. Medical decision-makers for patients hospitalized in hospice wards were recruited between September 2019 and July 2021. A medical decision-maker is a family member who makes medical decisions for a patient. All 146 participants completed a self-developed 10-item questionnaire that included five items about their demographic characteristics and five items about the decision-making process. The semi-structured interviews were conducted with nine participants to understand the family’s decision-making process when they chose a hospice ward. The interviews were analyzed using qualitative content analysis.

Results

The mean age of the 146 participants was 57.6 years old. Of the decision-makers, 56.85% were the patients’ children. Family-dominated discussions involving other family members were the main decision-making mode (84.93%). Patient participation in the decision-making process was reported in 43.15% of families. The participation of doctors (17.81%) and nurses (2.05%) were reported in a small number of families. The most common reason for choosing the hospice ward was the inability to find any other hospital for the patients (82.19%). The most common ways to learn about the service were neighbors and friends (38.36%) and social media (28.77%). Two themes and six categories emerged from the interviews. The first theme was reasons for choosing hospice wards. The reasons included being unable to care for the patients at home, staying in a hospice ward could reduce the psychological stress for home care, being unable to be admitted into tertiary/secondary hospitals, and thinking a hospice ward was a suitable place for the family. The second theme was the decision process of choosing a hospice ward. This theme included the following two categories, i.e., ways to learn about the hospice ward and family-discussion decision mode.

Conclusion

To most families having dying patients, a hospice ward is a reasonable and balanced choice after the families experience huge care stress and practical difficulties. The participation of patients should be encouraged in the family discussion so that their wishes can be known. More efforts will be needed to guide the families with dying patients to make reasonable medical choices. Social media can be a good way to improve public awareness of hospice services in the future. Meanwhile, healthcare providers should be more involved in the decision-making process.

End-of-life care preferences among cancer patients in Southern Thailand: a university hospital-based cross-sectional survey

BACKGROUND

End-of-life care preferences may be highly individual, heterogenic, and variable according to culture and belief. This study aimed to explore preferences and factors associated with end-of-life care among Thai cancer patients. Its findings could help optimize the quality of life of palliative cancer patients.

METHODS

A cross-sectional study surveyed palliative cancer outpatients at Songklanagarind Hospital from August to November 2020. The questionnaires inquired about: (1) personal and demographic information, (2) experiences with end-of-life care for their relatives, and (3) end-of-life care preferences. To determine end-of life preferences, the data were analyzed using descriptive statistics. The data concerning patient demographics and end-of-life care preferences were compared using Fisher's exact test.

RESULTS

The majority of the 96 palliative cancer outpatients were female (65.6 %), and the overall mean age was 55.8 ± 11.6 years. More than half of them had an experience of observing someone die (68.8 %), and they were predominantly being conscious until the time of death (68.2 %). Most participants preferred receiving the full truth satisfied with the care their relatives had received in passing away at home surrounded by family (47.0 %) and regarding their illness (99.0 %), being free of uncomfortable symptoms (96.9 %), having their loved ones around (93.8 %), being mentally aware at the last hour (93.8 %), and having the sense of being meaningful in life (92.7 %). Their 3 most important end-of-life care wishes were receiving the full truth regarding their illness, disclosing the full truth regarding their illness to family members, and passing away at home.

CONCLUSIONS

In order to optimize the quality of life of palliative cancer patients, end-of-life care should ensure they receive the full truth regarding their illness, experience no distressing symptoms, remain mentally aware at the last hour of life, feel meaningful in life, and pass away comfortably with loved ones around.

The Journey of the Purple Butterfly: A Quality Improvement Initiative

INTRODUCTION

Dying in the hospital is not always a good experience for patients and their families. To be more in line with evidence-based practices for healthcare workers to effectively support high quality end of life care, the project team implemented a standardized communication tool to alert interdisciplinary team members of patients on comfort care measures.

METHODS

Purple Butterfly was a quality improvement project that was implemented at a diverse community hospital in the urban setting. Clinical and non-clinical interdisciplinary team members participated in a pre- and post- implementation survey to assess the need for a standardized communication tool that would alert them of patients who transitioned to comfort care.

RESULTS

Pre-implementation, 37% of survey respondents (n = 60) reported they were always aware of the presence of a patient on comfort care measures prior to entering the room. After implementation of a standardized communication tool, 100% (n = 43) of respondents at 9 months, reported that they were always aware of the presence of a patient on comfort care measures prior to entering the room. Additionally, 9 months post-intervention 100% of respondents reported that knowing this contextual information supported them in performing their job duties in a compassionate, patient-centered fashion.

CONCLUSION

Implementation of a standardized communication tool increased awareness for team members, about the presence of patients on comfort care measures prior to entering the room and supported team members to perform their job duties in a compassionate, patient-centered fashion supportive of this patient population.

Palliative care needs and preferences of female patients and their caregivers in Ethiopia: A rapid program evaluation in Addis Ababa and Sidama zone

INTRODUCTION

In Ethiopia there is an extensive unmet need for palliative care, while the burden of non-communicable diseases and cancer is increasing. This study aimed to explore palliative care needs and preferences of patients, their caregivers, and the perspective of stakeholders on service provision in palliative programs for women, mostly affected by cervical cancer and breast cancer.

METHODS

A rapid program evaluation using a qualitative study approach was conducted in three home-based palliative care programs in Addis Ababa and Yirgalem town, Ethiopia. Female patients enrolled in the programs, and their primary caregivers were interviewed on palliative care needs, preferences and service provision. We explored the views of purposely selected stakeholders on the organization of palliative care and its challenges. Audio-taped data was transcribed verbatim and translated into English and an inductive thematic analysis was applied. Descriptive analyses were used to label physical signs and symptoms using palliative outcome scale score.

RESULTS

A total of 77 interviews (34 patients, 12 primary caregivers, 15 voluntary caregivers, 16 stakeholders) were conducted. The main physical complaints were moderate to severe pain (70.6%), followed by anorexia (50.0%), insomnia, nausea and vomiting (41.2%). Social interaction and daily activities were hampered by the patients' condition. Both patients and caregivers reported that programs focus most on treatment of symptoms, with limited psychosocial, emotional, spiritual and economic support. Lack of organizational structures and policy directions limit the collaboration between stakeholders and the availability of holistic home-based palliative care services.

CONCLUSIONS

Although female patients and caregivers appreciated the palliative care and support provided, the existing services did not cover all needs. Pain management and all other needed supports were lacking. Multi-sectorial collaboration with active involvement of community-based structures is needed to improve quality of care and access to holistic palliative care services.

Bereaved families' experiences of end-of-life decision making for general medicine patients

BACKGROUND

Family involvement in decision making for hospitalised patients is associated with improved end-of-life care. Yet, these discussions can be challenging for physicians and families and associated with distress, confusion and conflict. There is a need to understand how best to support families involved in decisions regarding the transition from active to palliative treatment in hospital settings.

AIM

To explore bereaved families' experiences of end-of-life decision making for general medicine patients.

DESIGN

A qualitative exploratory study framed by social constructionism using semistructured interviews and thematic analysis.

SETTING AND PARTICIPANTS

The general medicine units of one large public hospital in Melbourne, Australia. We recruited 28 bereaved family members of patients who had received end-of-life care.

FINDINGS

Patients and families depended on physicians to explain clinical complexity and treatment beneficence; however, trust in medical judgement was mediated by participant's own interpretations of clinical progress. Families sought to be respected as advocates and experienced distress if physicians disregarded their perspectives and insight concerning patient preferences. Ideally, families supported patients to express their preferences to physicians. Otherwise, families contextualised treatment decisions through their knowledge of patient's values and quality of life. Families often felt burdened by or excluded from medical decision making and experienced distress and confusion regarding their rights to request or refuse treatment.

CONCLUSION

Our study highlights how families contribute to decision making to ensure end-of-life care treatments reflect patient preferences. Physicians can ease families' distress around treatment withdrawal by providing a meaningful explanation of complex clinical issues, clarifying decision-making roles and acknowledge families' desire to protect and advocate for their loved one.

Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes

CONTEXT

There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations.

OBJECTIVES

This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China.

METHODS

Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence.

RESULTS

Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence.

CONCLUSION

Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.

Families' Experiences of End-of-Life Care at Home for Iranian Older Adults: A Qualitative Study

Aim:

While the care of dying elderly patients at home is very complex and ambiguous, it has not been studied in Iran so far. Hence, this study aimed to explore the experience of a representative sample of the Iranian family caregivers from the end-of-life (EOL) care for their elderly relatives.

Methods:

The present study was conducted using a qualitative content analysis method. Twelve family caregivers caring for the chronically ill dying elderly were selected using purposeful sampling. The purposive sampling method was applied with an extreme variation in sampling, and data gathering was pursued until data saturation was achieved. Semi-structured interviews were utilized for data collection. Interviews were recorded and instantly transcribed verbatim. Inductive content analysis was used to analyze the data.

Results:

Four core themes and 13 subthemes emerged from the experiences of family's caregiver as fallow: (1) Committed to care: This is related to encounter with the end of stage disease of the relative, accepting the care role and priority of care, (2) challenges of Care: Caregivers, despite their efforts, provided ineffective care, so they sought to empower themselves and at the same time provide compassionate care, (3) the crisis of care including the complexity of care, fear, and wandering, helplessness, devastating tension, and vacuum of supporting, and (4) conditions after death that family members involved with a sense of loss and Tension control.

Conclusion:

When families had to take care of their elderly patients at home, although their wish to give the best care, they are completely powerless to provide care, and in an atmosphere of the vacuum of supporting, they encounter severe challenges and crisis. It is vital that palliative care centers in the society are arranged to care for EOL elderly with comprehensive insurance services.

Transitions during end-of-life care from the perspective of informal caregivers - A concept analysis using Rodgers' (2000) evolutionary approach

PURPOSE

To produce a conceptual and operational definition of transition, in the context of end-of-life care, as experienced by informal caregivers.

METHODS AND SAMPLE

The authors used Rodgers' (2000) concept analysis framework to examine this concept.

FINDINGS

Common themes emerged using Rodgers' (2000) inductive approach confirming transition for informal caregivers at the end of life as a process comprising the presence of trigger(s)/event(s), awareness, instability and engagement/learning while maintaining normality. There was also duration to this process that was often unknown and unpredictable. This concept analysis provides useful insight into understanding the complex dynamics of transition during this period. The primary antecedent of this concept, prompting transition, is a diagnosis of non-curative disease for the patient. In some cases, a gradual realisation rather than a formal diagnosis that the illness has progressed to a non-curative stage, can also be an antecedent.

CONCLUSION

Transition during end-of-life-care for informal caregivers can be a highly emotional time for this vulnerable cohort. Effective transitioning can ensure a stability and quality end-of-life outcomes, such as a peaceful death, as the awareness and learning that it brings, prompts planning actions for terminal care. Through recognising the findings of this concept analysis, deeper insight may be gained to support the provision of care, by nurses, to informal caregivers, prompting them towards effective transitions that foster the best interest of the patient.

Hospice Care Provider Perspectives of Medical Assistance in Dying in a Canadian Hospice That Does Not Provide Medical Assistance in Dying

BACKGROUND

Medical assistance in Dying (MAiD) is offered across diverse settings, including hospices. There is little research exploring the experiences of hospice care providers who support patients who undergo MAiD at an off-site location.

PURPOSE

To describe hospice care provider perceptions of MAiD in an in-patient hospice facility that does not provide MAiD.

METHODS

Participants included hospice administrators, nurses, staff and volunteers who provide care at an in-patient hospice facility in a geographically isolated medium sized city (population <100,000) in a western Canadian province. Using a qualitative descriptive approach, eight in-depth semi-structured interviews were undertaken. Data were digitally recorded, transcribed, analyzed inductively, and organized thematically.

RESULTS

Introduction of MAiD challenged and disrupted care practices. Themes included: Situating MAiD within hospice and palliative care, caring for patients undergoing MAiD within a non-provider facility, and balancing interpersonal dynamics in an interdisciplinary team environment. Themes were underpinned by participants' attempts to reconcile MAiD within personal beliefs and work environment.

CONCLUSION

Caring for patients who chose MAiD changed the dynamic of care. Participants focused on providing patient-centred care while attempting to normalize the MAiD process. Educational resources to support patient-centred care for patients who undergo MAiD off-site, address care provider self-care, and to facilitate safe and effective interdisciplinary communication are needed.

Hospital Nurses' Perception of Death and Self-Reported Performance of End-of-Life Care: Mediating Role of Attitude towards End-of-Life Care

Few studies have explored how nurses in acute care hospitals perceive and perform end-of-life care in Korea. Therefore, this study aimed to evaluate the influence of nurses' perceptions of death on end-of-life care performance and analyze the mediating role of attitude towards end-of-life care among hospital nurses. This cross-sectional study included a total of 250 nurses who have had experience with end-of-life care from four general hospitals in Korea. We used the Korean validated tools with the View of Life and Death Scale, the Frommelt Attitudes Toward Care of the Dying (FATCOD) scale, and the performance of end-of-life care. Hierarchical linear regression and mediation analysis, applying the bootstrapping method. The results of hierarchical linear regression showed that nurses' positive perceptions of death and attitude towards end-of-life care were significantly associated with their performance of end-of-life care. A mediation analysis further revealed that nurses' attitude towards end-of-life care mediates the relationship between the perceptions of death and performance of end-of-life care. Our findings suggest that supportive and practical death educational programs should be designed, based on nurses' professional experience and work environment, which will enable them to provide better end-of-life care.

Impact of a Hospital Community Based Palliative Care Partnership: Continuum from Hospital to Home

Objectives: To discuss the outcomes of a formalized care transition process for palliative care patients from the hospital to the community. Background: Patients who received inpatient palliative care services from the specialist palliative care team in the hospital or who were identified as needing community palliative care services have inadequate support on discharge. Methods: A retrospective review of the medical records of patients admitted to the community based palliative care (CBPC) program, Arizona Palliative Home Care (AZPHC) over a 12-month period (June 2018 to May 2019) was undertaken with a focus on the frequency and pattern of hospital events pre- and postadmission to the program. Patient/family satisfaction data obtained from telephone surveys were evaluated. The medical records from patients (n = 294) with advanced complex illnesses who were admitted to AZPHC from the five Honor Health Network hospitals were included in this study. Results: Of the 294 patients' records reviewed, 80% were in the 65 and older age group and had a mean length of stay on AZPHC of ∼40 days. Comparing acute care utilization pre and post AZPHC admission, there was a reduction of 68.95% at 60 days and 68.22% at 90 days. In addition, 128 avoided hospital events were recorded, and 86% of patients were very likely to recommend AZPHC to family or friends. Discussion: Collaboration between a hospital palliative care team and a CBPC program resulted in high quality transitions across care settings and reduction in acute care utilization.

Work environment factors in coping with patient death among Spanish nurses: a cross-sectional survey

Objective:

to explore self-perception competence among Spanish nurses dealing with patient death and its relationship with work environment, evidence-based practice, and occupational stress.

Method:

a cross-sectional web-based survey collected information from a convenience sample of 534 nurses from professional Spanish Colleges who answered four validated questionnaires: Coping with Death Scale, Practice Environment Scale of the Nursing Work Index, Perception of Evidence-Based Practice (EBP) and Nursing Stress Scale.

Results:

a total of 79% of the participants were women, the average age was 40 years old, 38% had a postgraduate degree and 77% worked in public health settings. Many nurses evaluated their work environment as unfavorable (66%), reported high occupational stress (83.5±14.9), and had high scores on knowledge/skills in EBP (47.9±11.3). However, 61.2% of them perceived an optimal coping (>157 score). The multivariate logistic model indicated positive associations with work environment and EBP characteristics (OR: 1.30, p=0.054; OR: 1.04, p=0.007; OR: 1.13, p<0.001, respectively) but negative associations with occupational stress and short work experience (OR: 0.98, p=0.0043; OR: 0.74, p<0.002, respectively). These factors explained 23.1% of the coping variance (p<0.001).

Conclusion:

although most nurses perceived optimal coping, the situation could be enhanced by modifying several contextual factors. The identification of these factors would improve the quality of end-of-life care by facilitating nursing management.

Does the Experience of Caring for a Severely Disabled Relative Impact Advance Care Planning? A Qualitative Study of Caregivers of Disabled Patients

The aging of the Taiwanese population has become a major issue. Previous research has focused on the burden and stress faced by caregivers, but has not explored how the experience of these caregivers influences decisions of advance care planning (ACP). Semi-structured and in-depth interviews were conducted. Qualitative content analysis was used to identify important themes. Five themes and fourteen sub-themes were identified: (1) Past experiences: patient wishes, professional recommendations, and expectation about disease progress; (2) Impact of care on family members: positive affirmation, open-minded life, social isolation and health effects, and financial and life planning effects; (3) Attitude toward life: not forcing to stay, and not becoming a burden, (4) Expected proxy dilemmas: torment between doing or not, seeing the extension of suffering and toil, and remorse and self-blame; (5) Expectation of end of life (EOL) care: caregiver's experience and EOL care decisions, and practicality of EOL decision making. After making multiple medical decisions for their disabled relatives, caregivers are able to calmly face their own medical decisions, and "not becoming a burden" is their primary consideration. It's suggested that implementation of shared decision-making on medical care for patients with chronic disability will not only improve the quality of their medical care but also reduce the development of remorse and guilty feelings of caregivers after making medical decisions.

An examination of home-based end-of-life care for cancer patients: a qualitative study

Background

Only a small number of patients have utilized the home-based end-of-life care service in Shanghai that has been offered since 2012. This study explores how home-based end-of-life care is delivered in community health service centers in Shanghai and examines the difficulties in the delivery of the care.

Methods

This was a qualitative study in which data were collected from interviews and analyzed using qualitative content analysis. Nineteen health care providers with experience in delivering home-based end-of-life care in 12 community health service centers were recruited. The interviews were conducted between August 2018 and February 2019.

Results

Four themes emerged from the interviews: (i) Patients under home-based end-of-life care: Patients receiving the care were cancer patients with less than 1 year of life expectancy. The criteria for patients were broad. (ii) Service structure: The service was delivered regularly by the physicians and nurses using the approaches of home visits and/or telephone follow-ups. (iii) Service process: The service consisted of multiple components, including monitoring the patient’s condition, managing the patient’s symptoms, giving daily care instructions, performing nursing procedures, and giving psychological support. However, most of the care focused on monitoring the patients and managing their physical discomfort. (iv) Difficulties in delivering care: Being unable to provide the service and feeling powerless when facing psycho-spiritual problems were the two major difficulties. Three factors contributed to the suspension of the service: The gap between the service and the needs of the patients, a lack of patients, and low work motivation. The demand that the truth be concealed from the families and their attitude of avoiding talking about death were the key factors of the failure of psycho-spiritual care.

Conclusions

Several issues should be addressed before the service can be further developed, including fully understanding the needs and preferences of local patients and their families, securing more financial support and a better supply of drugs, delivering better training for staff, and ensuring greater rewards for individuals and institutions providing the service.