Dying in hospital in Germany - optimising care in the dying phase: study protocol for a multi-centre bottom-up intervention on ward level

Dying in hospital: a retrospective medical record analysis on care in the dying phase in intensive care units and general wards

BACKGROUND

Care in the dying phase is often suboptimal in hospitals outside specialized palliative care. Studies of the implementation of recommendations for care in the dying phase are rare. Medical records can provide information in this regard.

METHODS

A retrospective analysis of medical records was conducted for 400 patients who died in six intensive care units (ICUs) and four general wards (GWs) at two German medical centres. To evaluate the care in the dying phase, we descriptively analysed 37 variables reflecting recommendations of the German Palliative Care Guideline. To identify factors associated with important aspects of care, seven of these variables were determined as appropriate for multiple logistic regression.

RESULTS

In 299/400 (74.8%) patients, recognition of the dying phase was documented. Patients with the ability to communicate were informed about the impending death in 46/121 (38.0%) and informal caregivers (ICs) in 282/390 (72.3%). Patients' wishes regarding care were documented in 33/122 (27.1%). Monitoring was rarely stopped before death, with significantly lower percentages in ICUs: e.g. vital signs in 30% [14.9% in ICUs vs. 52.9% in GWs; confidence interval (28.4, 47.6)]. Validated symptom assessment tools were used in 272/400 (68.0%), mainly for pain (66.3%). Logistic regression analysis identified setting (ICUs vs. GWs), recognition of the dying phase, patient age, communication ability, and malignant neoplasm as factors significantly associated with aspects of care.

CONCLUSION

The dying phase was not consistently documented, many presumably nonbeneficial interventions continued until death, systematic symptom assessment beyond pain was lacking, and communication with patients and ICs was poorly documented. Findings suggest a need for setting-specific strengthening of healthcare professionals in these settings.

Care for the Dying: A Scoping Review of Measures for Clinical Practice With Qualitative Synthesis

The literature describes a plethora of different measures to support healthcare professionals in the care for the dying. The aim is the identification and assessment of measures for the care in the dying phase to give healthcare professionals of all disciplines an overview on such measures in form of a self-developed toolkit. Two databases were searched systematically and all measures found (n = 7368 publications, n = 308 measures) were categorized into six categories and integrated into a toolkit. Descriptive statistics and qualitative synthesis were used to report the findings. 50.6% of the measures were applied in studies with moderate level of evidence and 23.4% were concerned with hospital care. Most measures were related to symptom relief. Measures from high quality studies are lacking and most measures were applied in palliative care specialists settings. The developed toolkit can serve as a resource for healthcare professionals to guide and stimulate healthcare professionals' clinical practice.

Quality of care in the last year of life: adaptation and validation of the German “Views of Informal Carers’ Evaluation of Services – Last Year of Life – Cologne”

Background

To inform quality improvement and strengthen services provided in the last year of life, measuring quality of care is essential. For Germany, data on care experiences in the last year of life that go beyond diagnoses and care settings are still rare. The aim of this study was to develop and validate a German version of the ‘Views of Informal Carers’ Evaluation of Services – Short Form (VOICES-SF)’ suitable to assess the quality of care and services received across settings and healthcare providers in the German setting in the last year of life (VOICES-LYOL-Cologne).

Methods

VOICES-SF was adapted and translated following the ‘TRAPD’ team approach. Data collected in a retrospective cross-sectional survey with bereaved relatives in the region of Cologne, Germany were used to assess validity and reliability.

Results

Data from 351 bereaved relatives of adult decedents were analysed. The VOICES-LYOL-Cologne demonstrated construct validity in performing according to expected patterns, i.e. correlation of scores to care experiences and significant variability based on care settings. It further correlated with the PACIC-S9 Proxy, indicating good criterion validity. The newly added scale “subjective experiences of process and outcome of care in the last year of life” showed good internal consistency for each given care setting, except for the homecare setting. Test-retest analyses revealed no significant differences in satisfaction ratings according to the length of time since the patient’s death. Overall, our data demonstrated the feasibility of collecting patient care experiences reported by proxy-respondents across multiple care settings.

Conclusion

VOICES-LYOL-Cologne is the first German instrument to analyse care experiences in the last year of life in a comprehensive manner and encourages further research in German-speaking countries. This instrument enables the comparison of quality of care between settings and may be used to inform local and national quality improvement activities.

Trial registration

This study was registered in the German Clinical Trials Register (DRKS00011925; Date of registration: 13/06/2017).

Meanings and Experiences of End-of-Life Patients and Their Family Caregivers in Hospital-to-Home Transitions: A Constructivist Grounded Theory Study

This study explored the meanings and experiences of patients with terminal chronic diseases and their caregivers, who face the imminence of death in the home environment after hospital discharge. The qualitative study used constructivist grounded theory. The participants were individuals with a terminal chronic illness, discharged to home, and their family caregivers. Data were gathered from in-depth interviews and field notes, and a comparative analysis was conducted to identify categories and codes, according to Charmaz's theory. The sample consisted of 21 participants. Three inter-related data categories emerged: "Floating between acceptance and resistance: Perceiving the proximity of death", "Analysing the end from other perspectives: it is in the encounter with death that life is understood" and "Accepting the path: between the love of letting go and the love of wanting to stay". The categories translate the reconstruction of those facing end-of-life occurring in the home environment. It is amid the imminence of death that life gains intensity and talking about the finitude of life configures an opportunity to see life from other perspectives. Giving voice to individuals facing the mishaps of a terminal illness fosters the path to a comfortable death. For health professionals, it is an opportunity to provide structured and humanized care with an ethical attitude, in defence of human dignity.