The influence of symptom severity of palliative care patients on their family caregivers

Family members' experiences of surrogate decision-making in hospice care: A systematic review of qualitative studies

BACKGROUND

Surrogate decision-makers play a key role in determining whether end-of-life patients receive hospice care. There is a need to better understand families' experiences of surrogate decision-making in hospice care for end-of-life patients to provide a basis for developing targeted interventions, such as decision support tools or counseling, to help family members navigate the decision-making process.

AIM

The aim was to analyze and synthesize global qualitative data on family members' experiences of surrogate decision-making regarding whether to receive hospice care for end-of-life patients.

DESIGN

This was a systematic review of qualitative studies.

DATA SOURCES

The PubMed, Web of Science, Cochrane Library, Embase, Cumulated Index to Nursing and Allied Health Literature, Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, WanFang and China Science and Technology Journal databases were searched from inception to September 2024. Studies related to family members making surrogate decisions about whether to receive hospice care for end-of-life patients were included.

REVIEW METHODS

This review was guided by the Joanna Briggs Institute Manual for Systematic reviews of qualitative evidence. Two reviewers independently screened the studies and extracted the data. The eligible studies were assessed via the Joanna Briggs Institute critical appraisal instrument for qualitative research. Thematic synthesis was guided by the method developed by Thomas and Harden.

RESULTS

A total of nine studies were included. The synthesis of qualitative data resulted in three themes: (1) Decision motivation between rationality and emotion. The reasons surrogate decision-makers considered hospice care for patients involved multiple aspects and were a result of both objective and subjective factors. (2) Decision preparation stemmed from knowledge and experience. A knowledge-based foundation and experiential grounding were needed to ensure that surrogate decision-makers make informed decision. (3) Decision reflection through looking back and forward. Surrogate decision-makers expressed satisfaction with the decision to choose hospice care for patients, coupled with serious consideration of personal future end-of-life decisions.

CONCLUSION

Determining whether patients receive hospice care at end of life is complex for family members. This process begins with the coexistence of rational and emotional motives for decision-making, involves preparation for decision-making through the acquisition of knowledge and experience about hospice care, and culminates in reflection on the entire decision-making process. These findings underscore the importance of providing sufficient informational and emotional support to family decision-makers, which can improve decision-making and promote more compassionate end-of-life care. Future research should focus on developing effective strategies to strengthen these support systems.

STUDY REGISTRATION

A protocol was registered on the PROSPERO (CRD42024526197).

The relationship between stress, social support, and quality of life among spouses of patients at the end-of-life stage in Thailand: A correlational study

Background

Non-communicable diseases have become a leading global health challenge, with mortality rates steadily rising. Insufficient patient care can worsen chronic illness, often placing significant caregiving responsibilities on the patient's spouse. In some cases, spouses may need to leave their jobs to provide full-time care, especially during the end-of-life stage. Spousal caregivers often face emotionally distressing circumstances while caring for their loved ones, which can lead to elevated stress levels. However, research indicates that adequate social support can improve caregivers' quality of life, reducing some of the burdens associated with end-of-life care.

Objectives

This study aimed to assess and analyze the relationships between stress, social support, and quality of life experienced by spousal caregivers in Thailand, guided by Lazarus and Folkman's (1984) Stress and Coping Theory.

Methods

A correlational descriptive study design was used. The study was conducted with 84 spouses of patients in the end-of-life stage at a university hospital between October 2021 and March 2022. Data were collected using a questionnaire covering stress, social support, and quality of life and analyzed using Pearson's Product Moment and Spearman Rank Correlation Coefficients.

Results

The majority of spouses were women aged between 31 and 83 years (Mean = 61.24, SD = 10.42). The mean stress level was 6.40 (SD = 1.62), the mean social support was 55.07 (SD = 9.06), and the mean quality of life was 94.69 (SD = 10.04). There was no significant correlation between social support and stress (r = -0.098, p = 0.373). However, stress was negatively correlated with quality of life (r = -0.299, p = 0.006), and social support was positively related to quality of life (r = 0.219, p = 0.045).

Conclusion

Spousal caregivers of patients at the end-of-life stage experienced varying levels of stress, social support, and quality of life. While no significant relationship was found between social support and stress, stress negatively impacted quality of life, while higher social support was associated with improved quality of life. Healthcare providers, especially nurses, should assess and address the stress, social support, and overall well-being of spousal caregivers to enhance their quality of life.

Caregiving Strain Mediates the Relationship Between Terminally Ill Patient's Physical Symptoms and Their Family Caregivers' Wellbeing: A Multicentered Longitudinal Study

Objectives: Research considered patient outcomes primarily over caregivers in end-of-life care settings. The importance of family caregivers (FCs) in end-of-life care draws growing awareness, evidenced by an increasing number of evaluations of caregiver-targeted interventions. Little is known of FCs' collateral benefits in patient-oriented home-based end-of-life care. The study aims to investigate FC outcomes and change mechanisms in patient-oriented care. Methods: A pre-post-test study. We recruited FCs whose patients with a life expectancy ≤ 6 months enrolled in home-based end-of-life care provided by service organizations in Hong Kong. Patients' symptoms, dimensions of caregiving strain (ie, perception of caregiving, empathetic strain, adjustment demands), and aspects of FCs' wellbeing (ie, perceived health, positive mood, life satisfaction, spiritual well-being) were measured at baseline (T0) and 3 months later (T1). Results: Of the 345 FCs at T0, 113 provided T1 measures. Three months after the service commenced, FCs' caregiving strain significantly reduced, and their positive mood improved. Alleviation of the patient's physical symptoms predicted FC better outcomes, including the perception of caregiving, empathetic strain, and wellbeing. Changes in perception of caregiving mediated the effects of changes in patients' physical symptoms on FCs' changes in life satisfaction and spiritual wellbeing. Changes in empathetic strain mediated the changes between patient's physical symptoms and FCs' positive mood. Conclusions: Collateral benefits of patient-oriented home-based end-of-life care were encouraging for FCs. Patient's physical symptom management matters to FCs' caregiving strain and wellbeing. The active ingredients modifying FCs' perception of caregiving and addressing empathetic strain may amplify their benefits in wellbeing.

Number of palliative care nurse home visits and duration of palliative care associated with domains of the Good Death Inventory: A national survey of bereaved family caregivers in a middle income country

Background

In the lower-middle-income country of Kazakhstan, palliative care services are in the early stages of integration into healthcare services. No prior studies have investigated associations between palliative care service factors and a good death in lower-middle-income countries, nor explored how palliative care nurses contribute to a good death. In this paper, a good death is referred to as the control of pain and symptoms, clear decision-making, a sense of closure, being recognized and perceived as an individual, preparation for death, and still being able to contribute to others, all taken together.

Objectives

To identify new opportunities for palliative care service nurses by investigating associations between palliative care service factors and a good death, as measured by the Good Death Inventory.

Methods

Family caretakers of deceased patients from palliative care units and hospices were surveyed across six different regions of Kazakhstan. Data collected included demographics for patients and caregivers, palliative care service data, and Good Death Inventory items. Poisson regression analysis with r variance and linear regressions were conducted to identify determinants for achieving a Good Death and for the 18 Good Death Inventory domains.

Results

Two hundred and eleven family caregivers participated in the survey. Bivariate analysis revealed five statistically significant associations (p ≤ 0.05) with the outcome of a good death. In multivariate linear regression analyses, a palliative care duration of greater-than-6-months, compared to less-than-1-month, was associated with improvements in 10 out of 18 domains of the Good Death Inventory (p ≤ 0.05). More-than-once-weekly palliative care home visits by nurses, compared to no visits, were also associated with improvements in four domains (p ≤ 0.05).

Conclusion

We provide new directions for improvements in palliative care services in low-middle-income countries, giving impetus for resource allocation to palliative care home visits by nurses for achieving a good death for greater numbers of patients.

Family caregivers and the ethical relevance of moral identity

Many people want to spend the last stages of their lives at home, in familiar surroundings, and possibly with people they know. However, this increasing desire on the part of older, ill, or even dying people also makes support from other people unavoidable, which in many cases involves family members, loved ones, or even friends. These family caregivers care for the person concerned, even though they lack the professional skills of nursing staff, for example, and have usually not been prepared for this task. This article focuses on the ethical significance of the moral identity of family caregivers. While the effects of this care constellation on the caregivers have often been discussed in the scientific literature, ethical considerations regarding moral identity have so far been neglected. In the first step, the question of what is actually meant by the term moral identity is examined. The second step shifts attention to those people who have taken on the care of a loved one. The relevance of this previously discussed identity is emphasized by using study results and work in this context, and placed in relation to family caregivers. The third step shows that (1) moral identity must be understood as a necessary prerequisite for adequate and humane care, (2) this identity can be enhanced through the caregiving relationship, and (3) the activities undertaken by family caregivers reveal their moral identity. These considerations are finally summarized, provided with ethical aspects, and awareness of this important work of family caregivers is raised.

Family Members' Explanatory Models of Cancer Anorexia-Cachexia

The experience of bearing witness to the lack of appetite and involuntary weight loss that characterizes cancer anorexia-cachexia syndrome (CACS) is reported to be stressful for family members. Research identifies that family members engage in a wide range of behaviors in response to a relative who shows minimal interest in eating and is literally 'wasting away' before their eyes. Some families, though concerned about the symptoms of CACS, do not dwell excessively on the patient's nutritional intake while others continually harass the patient to eat and petition health care providers for aggressive nutritional interventions to eat in an attempt to stave off further physical deterioration. While studies have detailed how family members respond to a terminally ill relative with CACS, empirical work explicating the explanatory models of CACS that they hold is lacking. Explanatory models (EMs) reflect the beliefs and ideas that families have about why illness and symptoms occur, the extent to which they can be controlled, how they should be treated, and how interventions should be evaluated. To address this gap in the literature, a grounded theory study guided by Kleinman's Explanatory Model questions was conducted with 25 family members of advanced cancer patients. The core category of 'Wayfaring' integrates the key categories of the model and maps onto Kleinman's questions about CACS onset, etiology, natural course, physiological processes/anatomical structures involved, treatment, and the impacts of disease on patient and family. Findings suggest that a divergence between some biomedical constructions of CACS and explanatory models held by family members may fuel the family-health care provider conflict, thereby providing direction for communication with families about care of the patient with anorexia-cachexia.

Benefit finding among family caregivers of patients with advanced cancer in a palliative treatment: a qualitative study

BACKGROUND

Benefit finding is the search for positive meaning from traumatic events, such as cancer. It can help caregivers have a positive experience in the caregiving process, relieve negative emotions, and reduce caregiving stress. The aim of this study was to explore benefit finding among caregivers of patients with advanced cancer in their palliative caregiving journey.

METHODS

An exploratory qualitative design of phenomenology was used. Semistructured interviews were conducted with 19 caregivers of palliative care patients with advanced cancer. The Colaizzi 7-step analysis was used to analyse, summarize, and extract themes from the interview data.

RESULTS

The study identified five themes of caregiver benefit finding in the caregiving process: personal growth, strengthened relationships with patients, adjustment and adaptation, perceived social support, and perceived meaning in life. Most caregivers reported a closer, more dependent relationship with the patient, and only one caregiver did not report any positive changes.

CONCLUSIONS

Caregivers of palliative care patients with advanced cancer can have positive experiences in their care. Healthcare professionals should focus on supporting caregivers and helping them find positive experiences to cope with the challenges of caregiving and improve their quality of life.

Spiritual Distress, Hopelessness, and Depression in Palliative Care: Simultaneous Concept Analysis

Spiritual distress, hopelessness, and depression are concepts that are often used in palliative care. A simultaneous concept analysis (SCA) of these concepts is needed to clarify the terminology used in palliative care. Therefore, the aim of this study is to conduct a SCA of spiritual distress, hopelessness, and depression in palliative care. A SCA was performed using the methodology of Haase's model. A literature search was conducted in March 2020 and updated in April 2022 and April 2024. The search was performed on the following online databases: CINAHL with Full-Text, MEDLINE with Full-Text, MedicLatina, LILACS, SciELO, and PubMed. The search was achieved without restrictions on the date of publication. A total of 84 articles were included in this study. The results highlight that the three concepts are different but also share some overlapping points. Spiritual distress is embedded in the rupture of their spiritual/religious belief systems, a lack of meaning in life, and existential issues. Hopelessness is a sense of giving up and an inability to control and fix the patient's situation. Finally, depression is a state of sadness with a multi-impaired situation. In conclusion, refining the three concepts in palliative care is essential since it promotes clarification and enhances knowledge development towards intervention.

Effects of Telemedicine on Informal Caregivers of Patients in Palliative Care: Systematic Review and Meta-Analysis

Background

Telemedicine technology is a rapidly developing field that shows immense potential for improving medical services. In palliative care, informal caregivers assume the primary responsibility in patient care and often face challenges such as increased physical and mental stress and declining health. In such cases, telemedicine interventions can provide support and improve their health outcomes. However, research findings regarding the use of telemedicine among informal caregivers are controversial, and the efficacy of telemedicine remains unclear.

Objective

This study aimed to evaluate the impacts of telemedicine on the burden, anxiety, depression, and quality of life of informal caregivers of patients in palliative care.

Methods

A systematic literature search was conducted using the PubMed, Embase, Web of Science, CENTRAL, PsycINFO, CINAHL Plus with Full Text, CBM, CNKI, WanFang, and VIP databases to identify relevant randomized controlled trials published from inception to March 2023. Two authors independently screened the studies and extracted the relevant information. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. Intervention effects were estimated and sensitivity analysis was conducted using Review Manager 5.4, whereas 95% prediction intervals (PIs) were calculated using R (version 4.3.2) and RStudio.

Results

A total of 9 randomized controlled trials were included in this study. The meta-analysis indicated that telemedicine has reduced the caregiving burden (standardized mean differences [SMD] -0.49, 95% CI -0.72 to -0.27; P<.001; 95% PI -0.86 to -0.13) and anxiety (SMD -0.23, 95% CI -0.40 to -0.06; P=.009; 95% PI -0.98 to 0.39) of informal caregivers; however, it did not affect depression (SMD -0.21, 95% CI -0.47 to 0.05; P=.11; 95% PI -0.94 to 0.51) or quality of life (SMD 0.35, 95% CI -0.20 to 0.89; P=.21; 95% PI -2.15 to 2.85).

Conclusions

Although telemedicine can alleviate the caregiving burden and anxiety of informal caregivers, it does not significantly reduce depression or improve their quality of life. Further high-quality, large-sample studies are needed to validate the effects of telemedicine. Furthermore, personalized intervention programs based on theoretical foundations are required to support caregivers.

Perceptions of Learners and Specialists Toward ECHO Palliative Care Project in Thailand

INTRODUCTION

The Extension of Community Health Outcomes (ECHO) is a global movement that aims to decentralize the knowledge of specialists to primary care. A pilot, ECHO palliative care project in Thailand, was introduced to enhance the implementation of palliative care practice.

OBJECTIVE

To assess learners' and palliative care specialists' perceptions toward the ECHO palliative care project to improve and expand the project in the future.

SETTING

A total of 15 hospitals in 7 provinces in Northern Thailand, including provincial and district hospitals.

METHODS

A qualitative study was conducted among learners (primary care providers) and palliative care specialists who participated in the pilot program. Semi-structured interviews were used to explore the potential impact of the project on clinical practice, the strengths and weaknesses of the ECHO program and platform in the Thai context, and suggestions for expansion. Thematic analysis was used for qualitative analysis. Pre- and post-confidence scores, using a 5-point Likert Scale, for palliative care practice among learners were analyzed using paired T-tests.

RESULTS

Twenty participants were interviewed: 15 learners and 5 palliative care specialists. The confidence in practicing palliative care after participating in the ECHO palliative care project significantly increased for the learners, from 2.93 (95% CI, 2.49-3.38) to 3.93 (95% CI, 3.68-4.19) points (P = .003). Three themes emerged through the process evaluation of the pilot ECHO palliative care project: (1) applicable lessons that can translate to practice, (2) an effective learning program and assessable platform, and (3) suggestions for expansion.

CONCLUSION

The ECHO palliative care project increased confidence in providing palliative care for primary care providers in Thailand. Through capacity building, participants reported applying the knowledge to improve local health services and develop a network for consultations and referrals. There is potential for expansion of the ECHO palliative care project in Thailand.

Family resilience and its influencing factors among advanced cancer patients and their family caregivers: a multilevel modeling analysis

BACKGROUND

Cancer is highly prevalent worldwide. Family resilience is a positive variable that helps families burdened by advanced cancer to cope effectively. This study aimed to describe the family resilience of advanced cancer patients and caregivers in dyads and identify its influencing factors at the individual and dyadic levels.

METHODS

This multisite cross-sectional study was conducted in oncology units in five tertiary hospitals in China. A total of 270 advanced cancer patient-caregiver dyads were recruited between June 2020 and March 2021. Patients' and caregivers' family resilience was measured by the Family Resilience Assessment Scale. Data on potential influencing factors, including demographic and disease-related characteristics as well as family sense of coherence, psychological resilience, perceived social support, symptom burden, and caregiver burden, were collected. Multilevel modeling analysis was adopted to control for the interdependence of the dyads.

RESULTS

A total of 241 dyads were included in the data analysis. The mean ages of patients and caregivers were 53.96 (SD 15.37) and 45.18 (SD 13.79) years, respectively. Most caregivers were spouses and adult children (45.6% and 39.0%, respectively). Patients reported a higher mean family resilience score than caregivers (152.56 vs. 149.87, respectively). Undergoing fewer than two types of treatment and a lower symptom burden of patients predicted higher patient (B = -9.702, -0.134, respectively) and caregiver (B = -5.462, -0.096, respectively) family resilience. Patients also reported higher family resilience under the following conditions: 1) were on a medical insurance plan other than the new rural cooperative medical system (B = 6.089), 2) had a better family sense of coherence (B = 0.415), 3) whose caregivers were unmarried (B = 8.618), perceived lower social support (B = -0.145) and higher psychological resilience (B = 0.313). Caregivers who were ≤ 44 years old (B = -3.221), had similar previous caregiving experience (B = 7.706), and had a stronger family sense of coherence (B = 0.391) reported higher family resilience.

CONCLUSIONS

Our findings highlight the importance of adopting a dyadic approach when caring for advanced cancer patients and their caregivers. Dyadic longitudinal research is suggested to discover more modifiable factors of family resilience and tailored interventions are needed to obtain optimal dyadic outcomes.

Contributing factors involved in the safety of elderly people with chronic illness in home healthcare: a qualitative study

INTRODUCTION

Patients receiving home care are often elderly people with chronic illnesses that increasingly experience patient safety barriers due to special care needs.

OBJECTIVE

The present study was conducted to determine the factors involved in the safety of elderly patients with chronic illnesses receiving home care.

METHODS

A qualitative study with a conventional content analysis method was conducted in home care agencies of Tehran, Iran from August 2020 to July 2022. For data generation, semistructured interviews were conducted with 11 nurses, 2 nurse assistants, 1 home care inspector (an expert working at the deputy of treatment) and 3 family caregivers. Moreover, four observational sessions were also held. Data analysis was done using the five-step Graneheim and Lundman method.

RESULTS

According to the results, the facilitators of the safety of the elderly patients with chronic illnesses included the family's participation, nurse's competence, efficiency of the home care agency management and patient's participation in patient safety. The barriers to patient safety included problems created by the family, nurse's incompetence, inefficiency of the home care agency, patient's prevention of patient safety, home care setting limitations and health system limitations.

CONCLUSION

The majority of the factors involved in the safety of elderly patients with chronic diseases receiving home care had dual roles and could serve as a double-edged sword to guarantee or hinder patient safety. Identification of the facilitators and barriers can assist nurses and the healthcare system in planning and implementing patient safety improvement programmes for elderly patients with chronic illnesses.

Effect of Self-Chosen Music in Alleviating the Burden on Family Caregivers of Patients with Advanced Cancer: A Randomised Controlled Trial

The experience of caregiver burden among family members of patients with advanced cancer is a common problem. The aim of this study was to determine whether the burden may be alleviated by means of a therapeutic approach based on self-chosen music. This randomised controlled trial (ClinicalTrials.gov, NCT04052074. Registered 9 August 2019) included 82 family caregivers of patients receiving home palliative care for advanced cancer. The intervention group (n = 41) listened to pre-recorded, self-chosen music for 30 min/day for seven consecutive days, while the control group (n = 41) listened to a recording of basic therapeutic education at the same frequency. The degree of burden was assessed by the Caregiver Strain Index (CSI), calculated before and after the seven-day intervention. According to this measure, caregiver burden fell significantly in the intervention group (CSI change: -0.56, SD 2.16) but increased in the control group (CSI change: +0.68, SD 1.47), with a significant group x moment interaction F(1, 80) = 9.30, p = 0.003, η²_p = 0.11. These results suggest that, in the short term at least, the use of therapy based on self-chosen music alleviates the burden on family caregivers of palliative cancer patients. Moreover, this therapy is easy to administer at home and does not present any problems in practice.

Exploring Differences in Caregiver Communication in Serious Illness

Background: Demographic factors, such as disease context and family relationships, are communication mediators and moderators; however, little is known about how understanding these factors can improve caregiver communication with providers. Recognition of communication differences among caregivers may aid the development of approaches to improve serious illness communication. Objective: To explore whether caregiver communication differs by disease context (cancer vs. dementia) and caregiver communication type (Manager, Carrier, Partner, and Lone). Caregiver communication type is based on communication patterns between the care recipient and caregiver. Design and Measurements: Caregivers of persons with cancer and/or dementia were surveyed from a U.S. national research registry website. Measures of caregiver communication included information needs, communication confidence, perception of provider understanding of the caregiver, perceived frequency of caregiver assessment, and caregiver stress. Analysis of variance (ANOVA) determined significant differences between caregiver communication (p < 0.05) based on disease context and caregiver communication type. Results: Cancer caregivers reported higher unrecognized-demanded information states (i.e., not recognizing information was needed), more communication confidence, and more frequent caregiver assessment compared to dementia caregivers. Among caregiver communication types, Manager caregiver types were more confident communicating than other caregiver types and perceived greater understanding by providers than the Lone caregiver type. Manager caregivers reported significantly less stress than other caregiver communication types. Conclusions: Understanding disease context and caregiver communication type may help improve caregiver communication with health care providers.

Accelerometer-Measured Physical Activity, Inactivity, and Related Factors in Family Caregivers of Patients with Terminal Cancer

The physical activity (PA) and inactivity of family caregivers of cancer patients were investigated and related to burden and quality of life through a cross-sectional multicentre study. A total of 75 caregivers were recruited from June 2020 to March 2021. The levels of PA and inactivity were estimated with a wrist accelerometer, 24 h a day, for 7 consecutive days. The Quality of Life Family Version, the Caregiver Strain Index, the total duration of care, the average number of hours spent in care, and the assistance received were registered. Our results showed that moderate-to-vigorous PA was 96.40 ± 46.93 min/day, with 90.7% of participants performing more than 150 min/week of physical activity, and this was significantly associated with age (r = −0.237). Daily inactivity was 665.78 ± 94.92 min, and inactivity for 20−30 min was significantly associated with caregiver burden (r = 0.232) and quality of life (r = −0.322). Compliance with the World Health Organization recommendations was significantly associated with a lower quality of life (r = −0.269). The strength of these associations was limited (r ~0.2). In conclusion, the PA performed by most caregivers met the established recommendations, although older caregivers (>65 years old) performed lower moderate-to-vigorous PA than younger ones. In addition, the mean inactive time was high (11 h/day), showing slight relationships with the burden and quality of life of caregivers.