Beyond Advance Directives: Addressing Communication Gaps and Caregiving Challenges at Life's End

CONTEXT

The premise of advance directives and care planning is to help people articulate and document their wishes so surrogate decision-makers and providers can honor them. However, beyond the completion of such a document, underlying challenges are often unaddressed OBJECTIVES: The overall purpose of the study was to investigate how communication, including but not limited to the completion of advance directives, and caregiving influenced family caregivers' experiences. Communication gaps and caregiving challenges that were unaddressed by advance directives are presented.

METHODS

Non-dominant simultaneous mixed-methods (QUAL-QUAN) were used to explore how end-of-life events influenced family caregivers. In-depth interviews were conducted with 108 caregivers about 4 months following the death of a family member who was in hospice care.

RESULTS

A majority (n = 90; 84.9%) had specific wishes about end-of-life treatment. Patients had a completed: Health Care Proxy-101 (93.3%); Living Will-43 (39.8%); Do Not Resuscitate orders (DNR)-82 (75.9%) and Medical Orders for Life Sustaining Treatment-40 (37%). A majority (n = 83; 76.9%) of caregivers said that they had "enough" or "just the right amount" of information to prepare for the patients' death. Five themes illustrated caregivers' experiences: Family Conflict; Patient/Family-Provider Conflict; Uncertainty, Caregiving Realities; Awareness-Avoidance of Dying.

CONCLUSION

A majority of had an advance directive, yet caregivers expressed feeling unprepared for decision-making, caregiving and discussing it with the dying person. The advance directive and care planning process fell short of providing needed communication, knowledge and preparation; it can be an opportunity for teaching, learning, preparing and supporting families at life's end.

Prehospital Providers' Perspectives about Online Medical Direction in Emergency End-of-Life Decision-Making

Background: End-of-life treatment decisions present special challenges for prehospital emergency providers. Paramedics regularly make value-laden choices that transcend technical judgment and professional skill, affecting the type of care, how and to whom it is provided. Changes in prehospital emergency care over the last decade have created new moral challenges for prehospital emergency providers; these changes have also accentuated the need for paramedics to make rapid and reasoned ethical judgments. Objective: The purpose of the study was to explore the decision-making process that occurs when prehospital emergency teams respond to an end-of-life call with a focus on how state authorized documents such as a Non-Hospital Do Not Resuscitate (NHDNR) or Medical/Physician's Orders for Life-Sustaining Treatment (MOLST/POLST) or lack thereof inform decision-making. This paper presents the specific circumstances that informed the need for intervention from Online Medical Direction (OLMD) framed in the perspectives and words of the prehospital providers seeking that assistance. Methods: This study involved in-depth in-person interviews with 50 providers to elicit participants' experiences in their own words using a semi-structured interview instrument. Interviews were audio recorded and transcribed with permission. Results: Five themes emerged that illuminated how and when OLMD was involved in emergency end-of-life decisions: Termination of Resuscitation (TOR); Family Revoked DNR; Missing Documents; No Documents and No CPR; and Unusual Situations. Participants illustrated how the decision to terminate efforts was best-supported when it was made by collaboration between the on-scene provider and OLMD. Participants described ethical dilemmas when families asked them to initiate CPR in the presence of DNR orders and cognitive dissonance when CPR has been initiated but a valid DNR/MOLST is subsequently located. Conclusions: The study findings demonstrate the invaluable contribution of OLMD for complex end-of-life care decisions by prehospital providers, especially when there are difficult legal, ethical, and logistical questions. OLMD provides far more than technical support.

Managing Death in the Field: Prehospital End-of-Life Care

CONTEXT

Historically, the focus of prehospital care has been life-saving treatment. In the absence of a nonhospital do-not-resuscitate (DNR) order, prehospital providers have been compelled to begin and continue resuscitation unless or until it was certain that the situation was futile; they have faced conflict when caregivers objected.

OBJECTIVES

The purpose of the study was to explore prehospital providers' perspectives on how legally binding documents (nonhospital DNR order/medical orders for life-sustaining treatment) informed end-of-life decision making and care.

METHODS

This exploratory study used mixed methods in a sequential nondominant two-stage convergent quantitative and qualitative design. Phase I involved the collection of survey data. Phase II involved in-person semistructured interviews.

RESULTS

Surveys were completed by 239 participants, and 50 follow-up interviews were conducted. Survey data suggested that 73.7% felt confident when there was a DNR order and they did not initiate resuscitation, and 58.2% felt confident working through family disagreement when cardiopulmonary resuscitation was requested but there was a DNR; 66.1% felt confident explaining the dying process when death was imminent, and 55.7% felt comfortable telling a family that a patient was dying. Four themes emerged: changing standards of care; eliminating false hope; transitioning care from patient to family; and transferring care after death.

CONCLUSION

Prehospital providers provide support and care when they tell families that someone has died. Being able to comfort and be present with acute grief on scene is an important and evolving role for prehospital providers who manage death in the field.

Navigating the Transition from Advanced Illness to Bereavement: How Provider Communication Informs Family-related Roles and Needs

Person-centered, family-oriented services are integral to palliative and end-of-life care. Effective communication with providers informs the quality of the dying experience for patients and how families fare in bereavement. This paper reports findings from a study exploring how communication and care in the later stages of an advanced illness influence family caregivers' well-being in bereavement. A concurrent triangulation design was used to analyze data collected during semi-structured interviews with 108 recently bereaved caregivers from a single hospice agency in Western New York. Findings from this study suggest that family caregivers assume the role of interpreter and advocate while engaged in both formal and informal communication with health care providers at the end of care-recipients' lives. Findings also suggest that families are more likely to feel emotionally prepared for loss and grief when health care providers are available to communicate in a concise, consistent, and compassionate manner. The results illuminate the important connection between communication during the transition from late-stage illness to end-of-life care and preparation for bereavement. The paper concludes with a discussion of how findings from this study align with recent concerted efforts to establish standards and competencies for social work education and practice in palliative care.

GOALS OF CARE IN END-STAGE RENAL DISEASE: THE INFLUENCE OF AGE AND MULTIMORBIDITY

The number of people with End Stage Renal Disease (ESRD) who need dialysis treatment has increased sharply among adults age 75+. Older adults on dialysis have lower rates of advance care planning and higher treatment intensity, hospitalization and intensive care than people other chronic illnesses. Comprehensive care of older adults with ESRD includes advance care planning that addresses goals of care and not just specific medical treatments. The purpose of this study was to explore the nature of symptom burden and advance care planning in dialysis patients. The study design was exploratory, descriptive and cross-sectional. Quantitative and qualitative data were collected during in-person chairside interviews with people having dialysis treatments. Categorical questions focused on demographics and advance directives. The Dialysis Symptom Inventory was used to measure symptom burden. Open-ended questions addressed the trajectory of illness and goals of care. Thirty-five interviews were conducted. Participants’ Mage=55.8 years (range 27-84); 51 % were >60. A distinctive pattern of difference by age emerged. Participants >60 demonstrated greater multimorbidity and lower symptom burden (MDSI=30.13; Range 11-63) compared with those <60 (MDSI=36.31; Range 3-78). Goals of care also varied with age. Older adults’ goals were: (1) Functional (e.g. to walk better, drive); and (2) Existential (e.g. maintaining, surviving, enjoying). Goals of participants <60 were: (1) Transplantation; and (2) Engagement (e.g. work, school, travel). The results suggest that the illness experience and goals are influenced by age and multimorbidity. Implications: ESRD-specific advance care planning conversations with a focus on goals of care are important.

MANAGING DEATH IN THE FIELD: HOW EMERGENCY MEDICAL SERVICES TEAMS PROVIDE END-OF-LIFE CARE

Emergency medical services (EMS) providers respond more frequently to calls for older adults with serious illness than for people in other age groups. Recent legislation that makes it possible to document healthcare decisions has facilitated an era of choice in end-of-life care. EMS teams make time-sensitive decisions about care, resuscitation and hospital transport that influence how and where a seriously ill older adult will die and how his/her family will experience the death. Yet, EMS providers’ perspectives on urgent decision-making and how they work with families are unknown. The purpose of this study was to explore the decision-making process that occurs how EMS teams respond when someone is dying from a serious illness (vs. an injury). In-depth in-person interviews were conducted with 50 EMS providers (24 emergency medical technicians [EMTs] and 26 Paramedics) from four ambulance services. Participants’ ages ranged from 21-57 (M=37.9) and 70% were male. Qualitative data was coded using Atlas.ti software. Three themes illuminated participants’ experiences with end-of-life calls: (1) How legally binding documents (e.g. Do Not Resuscitate [DNR] orders, Medical Orders for Life Sustaining Treatment [MOLST]) inform care; (2) Decision-making about foregoing or halting resuscitation (e.g. no hospitalization, death at home); and (3) Family care, support and education. The results suggest that EMS providers have critically important roles in upholding the wishes of seriously ill older adults and helping caregiving families through the end-of-life transition. Implications: Discussions about the meaning of legally binding documents (e.g. DNR, MOLST) and EMS calls are important in advance care planning.

PLACE MATTERS: HOW LOCATION AT DEATH INFLUENCES CAREGIVER WELL-BEING IN BEREAVEMENT

Most older adults express the preference to die at home, but the desire for home death may go unfulfilled when the dying process become burdensome. Little is known about the congruence between older adults’ and their caregivers’ desired locations at death. The purpose of this study was to explore how the congruence between caregiver-care recipients desired and actual location at death influenced well-being in bereavement. This exploratory study utilized simultaneous qualitative and quantitative methods. Interviews were conducted with 108 bereaved caregivers about 4 months after the care recipient died while receiving hospice care. Care recipients’ ages ranged from 43-101 (M=79.6); caregivers from 32-88 (M=61.5). Quantitative data included categorical variables about demographics, advance care planning and location at death. The Core Bereavement Items and CDC HRQOL–14 "Healthy Days Measure" scales were used. Qualitative data involved open-ended questions about the illness trajectory, desired location and perceptions of care at life’s end. Quantitative analysis included comparison of group differences using both Independent Samples t-tests and One-way ANOVA. Of the 92 care recipients who had an advance directive, N=49 (45%) were in the location they desired and for N=49 (45%) there was caregiver/care recipient congruence about location. Caregivers who experienced incongruence reported poorer physical and emotional well-being and higher, more intense bereavement symptoms. Three overarching themes illuminated caregivers’ experiences: (1) Caregiver-recipient congruence; (2) Caregiver-recipient incongruence; (3) Incongruence-influenced bereavement. Results suggest that incongruence between desired and actual location of death affects well-being in bereavement. Implications: Communication about location at death is an essential consideration.

Transport Home and Terminal Extubation by Emergency Medical Services: An Example of Innovation in End-of-Life Care

For most terminally ill patients, the preferred place of death is home. Previous literature has demonstrated the feasibility of at-home terminal extubation performed by critical care and hospice physicians. This case report describes a terminal extubation performed by a paramedic under the direct supervision of an Emergency Medical Services physician in the patient's home. Guided by a comprehensive plan and logistical support from a team of hospice providers, a successful out-of-hospital terminal extubation is possible. To truly achieve patient-centered care at end of life, the choice for an out-of-hospital death is necessary.

Understanding Family Responses to Life-Limiting Illness: In-depth Interviews with Hospice Patients and Their Family Members

Understanding family dynamics is a key component in providing comprehensive care for persons with progressive illnesses and their caregivers. The purpose of this study was to investigate what families experience during an advancing illness and to describe their patterns of response. In-depth interviews (n=108) were conducted with families two weeks after hospice admission. Interviews were tape recorded, transcribed, and analyzed using qualitative methods. Six modes were distilled: reactive (illness generates intense responses), advocacy (vulnerability ignites assertive actions), fused (illness and decline are shared experiences), dissonant (diametrically opposed viewpoints cause struggle), resigned (decline and death are anticipated), and closed (outward responses are impassive). Three events triggered movement from one mode to another: (1) functional changes, (2) crisis events, and (3) provider communication. Providers who understand varied family reactions can ease the patient's suffering, assist relatives in providing effective care, and prepare them for the approaching death.

Crisis in Caregiving: When Home-Based End-Of-Life Care is No Longer Possible

Understanding the factors that precipitate caregiving crises that cannot be resolved at home is central to improving options for care at life's end. The purpose of this study was to explore caregivers’ perceptions of the crises that preceded and were resolved by relocation during end-of-life care. In-depth interviews were conducted with 36 caregivers of people who died in a hospice house. The results illuminate a conceptual model of the caregiving crisis, which has three stages: a) precipitating factors — the interrelationship between illness trajectory and reciprocal suffering (physical, psychological, emotional and social distress), b) crisis, and c) resolution (settled or unsettled). Relocation presents an opportunity for families to relinquish the burden of end-stage care so that they can resume and complete a lifelong relationship. Careful recognition of and attention to the intimate dynamics that accompany suffering and dying are essential elements of palliative care, which aims to uphold the dignity of the dying person and the integrity of the family in both caregiving and bereavement.

The Nexus Between the Documentation of End-of-Life Wishes and Awareness of Dying: A Model for Research, Education and Care

The convergence of medical treatment that can extend life with written medical orders that make it possible to refuse such treatment brings the differential dynamics of contemporary end-of-life decision making into sharp focus. Communication between families and clinicians can be confusing, uncertain, and pressured when death is imminent. These situations create distress that ultimately influences the end-of-life experience for people who are dying and those who care for them. This article presents the analysis of the decisional dynamics that emerge from the intersection of the patient-family-provider awareness that death is near with the presence or absence of documentation of expressed wishes for end-of-life care. A heuristic analysis was conducted with data from three studies about urgent decision making at the end of life. Original study data included 395 surveys, in-depth interviews with 91 prehospital (paramedics and emergency medical technicians), and content analysis of 100 Medical Orders for Life Sustaining Treatment forms that led to the development of an overarching conceptual model of decision making. Four decisional contexts emerged from the intersection of awareness of dying and documentation of wishes: 1) Aware Documented, 2) Aware Undocumented, 3) Unaware Documented, and 4) Unaware Undocumented. This generalizable model, which is agnostic of setting, can help clinicians more astutely recognize the clinical situation when death is imminent, assess patients and caregivers, and intervene to help focus conversation and direct decision making. The model can also inform research, education, and care for people in some of the most vulnerable moments of life.

Changing Focus: End-of-Life Care in a New York State Managed Long-Term Care Program

In the United States, managed long-term care programs offer a noninstitutional approach to meeting the needs of increasing numbers of frail elders. Providing services that support both quality of life and quality of dying poses unique challenges. Using a qualitative descriptive design, we explored these challenges from the perspectives of care providers. Themes were identified using qualitative content analysis techniques applied to transcripts of 33 semistructured interviews. Professionals comprising an interdisciplinary care team and home health aide direct care providers described cues by which they identified movement into the end-of-life phase, their understandings of how care changed, and their concerns and recommendations for improvement. When the changing care needs could be met, a "good death" ensued, but that was not always possible. Managed long-term care programs are called upon to develop the capacity to integrate the phase of dying into the full story of each life for which they care.

Emergency medical services providers' perspective of end-of-life decision making for people with intellectual disabilities

BACKGROUND

Emergency medical services (EMS) providers are often called to rapidly determine and act upon patients' wishes for end-of-life care. People with intellectual disabilities are living increasingly longer with complex conditions leading to international calls for person-centred advance care planning. Yet, best estimates suggest that very few people with intellectual disabilities document their wishes.

METHODS

This exploratory-descriptive study incorporated mixed methods to analyse data collected consecutively (surveys, n = 239; interviews, n = 48) with EMS providers from five agencies. Data were subjected to a sequential quantitative-qualitative analysis applying a critical discourse analysis framework.

RESULTS

Findings indicate that 62.7% had treated a person with intellectual disability who had medical orders directing end-of-life care. Three themes (provider familiarity, organizational processes, sociocultural context) offer insights about how medical orders inform EMS providers during calls involving people with intellectual disabilities.

CONCLUSION

Multiple contexts influence how wishes are documented and care provided to people with intellectual disabilities near life's end.

Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care

OBJECTIVES

What patients intend when they make health care choices and whether they understand the meaning of orders for life-sustaining treatment forms is not well understood. The purpose of this study was to analyze the directives from a sample of emergency department (ED) patients' MOLST forms.

PROCEDURES

MOLST forms that accompanied 100 patients who were transported to an ED were collected and their contents analyzed. Data categories included age, gender, if the patient completed the form for themselves, medical orders for life-sustaining treatment including intubation, ventilation, artificial nutrition, artificial fluids or other treatment, and wishes for future hospitalization or transfer. Frequencies of variables were calculated and the associations between them were determined using chi-square. An a priori list of combinations of medical orders that were contradictory was developed. Contradictions with Orders for CPR (cardiopulmonary resuscitation) included the choice of one or more of the following: Comfort care; Limited intervention; Do Not Intubate; No rehospitalization; No IV (intravenous) fluids; and No antibiotics. Contradictions with DNR orders included the choice of one or more of the following: Intubation; No limitation on interventions. Contradictions with orders for Comfort Care were as follows: Send to the hospital; Trial period of IV fluids; Antibiotics. The frequencies of coexisting but contradictory medical orders were calculated using crosstabs. Free text responses to the "other instructions" section were submitted to content analysis.

RESULTS

Sixty-nine percent of forms reviewed had at least one section left blank. Inconsistencies were found in patient wishes among a subset (14%) of patients, wherein their desire for "comfort measures only" seemed contradicted by a desire to be sent to the hospital, receive IV fluids, and/or receive antibiotics.

CONCLUSIONS

Patients and proxies may believe that making choices and documenting some, but not all, of their wishes on the MOLST form is sufficient for directing their end-of-life care. The result of making some, but not all, choices may result in patients receiving undesired, extraordinary, or invasive care.

Is It the Difference a Day Makes? Bereaved Caregivers' Perceptions of Short Hospice Enrollment

CONTEXT

Hospice enrollment for less than one month has been considered too late by some caregivers and at the right time for others. Perceptions of the appropriate time for hospice enrollment in cancer are not well understood.

OBJECTIVES

The objectives of the study were to identify contributing factors of hospice utilization in cancer for ≤7 days, to describe and compare caregivers' perceptions of this as "too late" or at the "right time."

METHODS

Semistructured, in-depth, in-person interviews were conducted with a sample subgroup of 45 bereaved caregivers of people who died from cancer within seven days of hospice enrollment. Interviews were transcribed and entered into Atlas.ti for coding. Data were grouped by participants' perceptions of the enrollment as "right time" or "too late."

RESULTS

Overall, the mean length of enrollment was MLOE = 3.77 (SD = 1.8) days and ranged from three hours to seven days. The "right time" group (N = 25 [56%]) had a MLOE = 4.28 (SD = 1.7) days. The "too late" group (N = 20 [44%]) had a MLOE = 3.06 (SD = 1.03) days. The difference was statistically significant (P = 0.029). Precipitating factors included: late-stage diagnosis, continuing treatment, avoidance, inadequate preparation, and systems barriers. The "right time" experience was characterized by: perceived comfort, family needs were met, preparedness for death. The "too late" experience was characterized by perceived suffering, unprepared for death, and death was abrupt.

CONCLUSION

The findings suggest that one more day of hospice care may increase perceived comfort, symptom management, and decreased suffering and signal the need for rapid response protocols.

"We Are Strangers Walking Into Their Life-Changing Event": How Prehospital Providers Manage Emergency Calls at the End of Life

CONTEXT

Emergency 911 calls are often made when the end stage of an advanced illness is accompanied by alarming symptoms and substantial anxiety for family caregivers, particularly when an approaching death is not anticipated. How prehospital providers (paramedics and emergency medical technicians) manage emergency calls near death influences how and where people will die, if their end-of-life choices are upheld and how appropriately health care resources are used.

OBJECTIVES

The purpose of this study was to explore and describe how prehospital providers assess and manage end-of-life emergency calls.

METHODS

In-depth and in-person interviews were conducted with 43 prehospital providers. Interviews were audiotaped, transcribed, and entered into ATLAS.ti for data management and coding. Qualitative data analysis involved systematic and axial coding to identify and describe emergent themes.

RESULTS

Four themes illustrate the nature and dynamics of emergency end-of-life calls: 1) multifocal assessment (e.g., of the patient, family, and environment), 2) family responses (e.g., emotional, behavioral), 3) conflicts (e.g., missing do-not-resuscitate order, patient-family conflicts), and 4) management of the dying process (e.g., family witnessed resuscitation or asking family to leave, decisions about hospital transport). After a rapid comprehensive multifocal assessment, family responses and the existence of conflicts mediate decision making about possible interventions.

CONCLUSION

The importance of managing symptom crises and stress responses that accompany the dying process is particularly germane to quality care at life's end. The results suggest the importance of increasing prehospital providers' abilities to uphold advance directives and patients' end-of-life wishes while managing family emotions near death.

Contending with advanced illness: patient and caregiver perspectives

CONTEXT

Despite improvements in end-of-life care, some unrelieved suffering persists for patients with advanced illness and their family members. Hospice and palliative care services can reduce suffering, but these services remain under-used.

OBJECTIVES

To investigate how patients with advanced illness and their primary caregivers experienced and responded to health care needs and decision making and how some dyads moved toward comfort-focused care.

METHODS

This was a qualitative study using the grounded theory method for sample selection, data collection, and analysis. Dyadic semi-structured interviews were audio-recorded and transcribed for analysis. Twenty-two participants, 12 patients and 10 family surrogates, provided 16 interviews for this study.

RESULTS

Participants engaged in a process of contending with advanced illness. The major phases comprising this process were suffering, struggling, and settling. Struggling included enduring the experience and fighting the illness. During the phase of settling, the focus shifted away from curative efforts and toward supportive care. Conditions that facilitated the movement into this phase included receiving clear and consistent information about the patient's health status, trusting health care providers, having attended to advance care planning in some form, and being aware of and able to acknowledge the terminal nature of the illness.

CONCLUSION

Findings from this pilot study offer a preliminary theoretical model to enhance the understanding of patient and family caregiver needs during advanced illness. Awareness of their perspective can inform the timing and content of clinicians' communication and interventions.

Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians

BACKGROUND

Prehospital emergency providers (emergency medical technicians [EMTs] and paramedics) who respond to emergency calls for patients near the end of life (EOL) make critical decisions in the field about initiating care and transport to an emergency department.

OBJECTIVE

To identify how a sample of prehospital providers learned about EOL care, their perceived confidence with and perspectives on improved preparation for such calls.

DESIGN

This descriptive study used a cross-sectional survey design with mixed methods.

SETTING/PARTICIPANTS

One hundred seventy-eight prehospital providers (76 EMT-basics and 102 paramedics) from an emergency medical services agency participated.

MEASUREMENTS

Multiple choice and open-ended survey questions addressed how they learned about EOL calls, their confidence with advance directives, and perspectives on improving care in the field.

RESULTS

The response rate was 86%. Education about do-not-resuscitate (DNR) orders was formal (92%), experiential (77%), and self-directed (38%). Education about medical orders for life-sustaining treatment (MOLST) was formal (72%), experiential (67%), and self-directed (25%). Ninety-three percent were confident in upholding a DNR order, 87% were confident interpreting MOLST, and 87% were confident sorting out conflict between differing patient and family wishes. Qualitative data analysis yielded six themes on improving preparation of prehospital providers for EOL calls: (1) prehospital provider education; (2) public education; (3) educating health care providers on scope of practice; (4) conflict resolution skills; (5) handling emotional families; and (6) clarification of transfer protocols.

CONCLUSION

These study results suggest the need for addressing the potential interrelationship between prehospital and EOL care through improved education and protocols for care in the field.

Communication and advanced care planning in palliative and end-of-life care

Communication about and planning for the end of life has evolved with medical and technological changes. This article presents a focused literature review of Advance Directives (ADs), Advanced Care Planning (ACP), and communication in palliative and end-of-life care. Two focused Medline searches were conducted to locate articles that addressed ACP in the U.S. Content analysis was utilized to summarize and categorize the literature into five domains: (1) ADs, (2) ACP and communication, (3) Barriers to ACP, (4) Differential domains of ACP, and (5) Interventions to enhance the process. Policies and protocols for ACP and communication have been developed to facilitate the process in different patient populations and locations of care. Effective ACP is an essential component of person-centered end-of-life and palliative care.

An exploratory analysis of intimate partner violence and postpartum depression in an impoverished urban population

Research on the relationship between intimate partner violence (IPV) and postpartum depression (PPD) is limited. Numerous antecedents and consequences of both IPV and PPD are noted in the literature; however, understanding the mechanisms by which intimate partner violence impacts the postpartum mood are not clearly understood. This study utilized retrospective chart reviews from a pediatric/perinatal social work outreach program to explore urban minority women experiences with IPV and depression both during pregnancy and after. Findings do not suggest a direct relationship between IPV and PPD; however, there was a high co-occurrence of prenatal depression and PPD. The severity of IPV appears to influence the occurrence and acuity of prenatal depression suggesting an indirect relationship. Implications for health and social work practitioners are discussed.

Hospice decision making: diagnosis makes a difference

PURPOSE

This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision.

METHODS

This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36 hospice patients and 55 caregivers after 2 weeks of hospice care. The study was guided by Janis and Mann's conflict theory model (CTM) of decision making. Qualitative data analysis involved a directed content analysis using concepts from the CTM.

RESULTS

A model of hospice enrollment decision making is presented. Concepts from the CTM (appraisal, surveying and weighing the alternatives, deliberations, adherence) were used as an organizing framework to illustrate the dynamics. Distinct differences were found by diagnosis (cancer vs. other chronic illness, e.g., heart and lung diseases) during the pre-encounter phase or before the hospice referral but no differences emerged during the post-encounter phase.

IMPLICATIONS

Differences in decision making by diagnosis suggest the need for research about effective means for tailored communication in end-of-life decision making by type of illness. Recognition that decision making about hospice admission varies is important for clinicians who aim to provide person-centered and family-focused care.

The nature and timing of family-provider communication in late-stage cancer: a qualitative study of caregivers' experiences

CONTEXT

Family members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved one's illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future.

OBJECTIVES

Guided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers' accounts of the nature and timing of communication they had with a loved one's health care provider(s) during the advanced stages of cancer and before hospice enrollment.

METHODS

Retrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes.

RESULTS

Overall, communication with providers was found to be either 1) satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death.

CONCLUSION

Communication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.

The living-dying interval in nursing home-based end-of-life care: family caregivers' experiences

Guided by concepts from the living-dying interval ( Pattison, 1977 ) this study sought to explore family members' experiences with a dying nursing home resident. In-depth interviews were conducted with 31 caregivers of residents who had died. Interviews were audiotaped and transcribed. Themes that illuminated families' experiences on the living-dying interval were: an acute medical crisis (trigger events, accumulation of stressors, level of care crisis); the living-dying phase (advance care planning, hospitalization, end-stage decisions); and the terminal phase (beginning of the end, awareness of dying). The results illustrate critical periods for social work intervention with families of dying nursing home residents.

Dental students' attitudes about older adults: do type and amount of contact make a difference?

This study was an extension of a previous study that considered dental student attitudes about older adults. In the current study, the association of student interactions with older adults, in both the dental school clinic and daily life, with their attitudes about this group was evaluated using the Aging Semantic Differential. A total of 311 dental students across all four years of academic standing were included in the study. The results showed that students' interactions with older adults outside the clinic did not relate to positive attitudes; however, even after controlling for the age of the student and the frequency, type of individual, and context of interactions with older adults outside the dental clinic, the number of older adult patients seen in the clinic showed a significant positive relationship with attitudes towards older adults. These results reinforce the conclusions drawn in a previous study that dental students' general attitudes about older adults may be changed, but that it is the exposure to older adults in a clinical setting that seems to be more critical in shaping these attitudes.

“Waiting for the other shoe to drop:” distress and coping during and after treatment for breast cancer

This study explored distress and coping strategies during and after breast cancer treatment. Open ended interview questions were used to explore stress and coping across the illness trajectory and during continuing care. With permission, 49 of the 50 interviews were audiotaped. Interviews also involved the use of the Impact of Events Scale-Revised (IES-R), the Ways of Coping (WAYS) and the Lubben Social Support Network Scale (LSNS-6). Data analysis involved a sequential quantitative (dominant)-qualitative (non-dominant) design.A mean-split procedure was used to compare lower and higher distress. The overall IES-R score as well as the Avoidance, Intrusions, and Hyperarousal subscales were all statistically significant between the higher-lower distress groups. Fourteen of the 22 individual IES-R items were significantly different between groups.WAYS subscale scores were not significantly different but 21% of the individual items were. Stress involves (1) physical stressors and(2) psychosocial stressors: (fear of recurrence and family-focused concerns). Coping involves (1) activity-based strategies, (2) cognitive strategies, and (3) spiritual strategies. Breast cancer survivors experience persistent concern about recurrence and uncertainty about the future. Understanding the nature of distress and how women cope during and after treatment are key to improved care for women who have breast cancer.

Crisis in caregiving: when home-based end-of-life care is no longer possible

Understanding the factors that precipitate caregiving crises that cannot be resolved at home is central to improving options for care at life's end. The purpose of this study was to explore caregivers' perceptions of the crises that preceded and were resolved by relocation during end-of-life care. In-depth interviews were conducted with 36 caregivers of people who died in a hospice house. The results illuminate a conceptual model of the caregiving crisis, which has three stages: (a) precipitating factors--the interrelationship between illness trajectory and reciprocal suffering (physical, psychological, emotional and social distress), (b) crisis, and (c) resolution (settled or unsettled). Relocation presents an opportunity for families to relinquish the burden of end-stage care so that they can resume and complete a lifelong relationship. Careful recognition of and attention to the intimate dynamics that accompany suffering and dying are essential elements of palliative care, which aims to uphold the dignity of the dying person and the integrity of the family in both caregiving and bereavement.

Making the transition to hospice: exploring hospice professionals' perspectives

Hospice care is available for 6 months before death but the length of use varies widely, suggesting that there are different perspectives on the appropriate timing for this transition. This qualitative study explored hospice professionals' views on the appropriate timing for and communication about hospice. Ethnography of team meetings informed the development of questions for focus groups and written follow-up surveys with 53 hospice professionals. Results suggest timely admissions are situation-specific and involve a terminal prognosis, terminal decline, and a mutual understanding. Important aspects of communication among families, physicians, and hospice teams are described.

Factors that influence dental students' attitudes about older adults

Our study considered dental students' general attitudes towards older persons using the Aging Semantic Differential. The influence of age, gender, cohort, education, and academic exposure on general attitudes towards older adults was evaluated using a total of 328 dental students across all four years of academic standing. Students were assessed in the fall and spring semesters. The results showed differential responding on the four subscales, with slight positive ratings on the autonomy, acceptability, and integrity subscales and a slight negative rating for instrumentality. Females expressed more negative attitudes than their male counterparts, with no age differences. There was also no significant impact from a specific, didactic educational component offered to the fourth-year students. However, the fourth-year students were the only group to show positive changes across the full academic year. The results suggest that general attitudes can be changed, but didactic (classroom) forms of education alone are insufficient to meaningfully modify students' perceptions of the elderly. Exposure to older adults in a clinical setting appears to be a critical element, as the fourth-year students received much greater exposure to older patients and more intensified interface with their mentors.

Treatment at the end of life

End-of-life care has gained recognition as an important interdisciplinary clinical domain during the past three decades largely because scientific and medical advances have changed the nature of dying in the US. Advances in the treatment of life-limiting ilness have typically focused on medical issues and on treating the physical symptoms that accompany the final stage of a terminal illness. However, because the lengthening life span has made more choices available at the end of life, there is also greater need for evidence-based psychosocial treatment to diminish some of the prolonged emotional, psychological treatment to diminish some of the prolonged emotional, psychological, social, and spiritual distress that accompanies dying. Both terminally ill older adults and their caregivers can be helped by interventions that address the need for information, education, preparation, communication, emotional support, and advocacy. This paper preents a review of evidence-based psychosocial treatments at the end of life for both older adults and their caregivers.

Caregiver grief in terminal illness and bereavement: a mixed-methods study

Caregivers experience multiple losses during the downhill trajectory of a loved one's terminal illness. Using mixed methods, this two-stage study explored caregiver grief during a terminal illness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression, and trouble concentrating, remembering, and getting things done. Following the death, caregiver grief became a state of sustained reactivity: Overall distress was diminished and anxiety and hostility decreased significantly, but loneliness, sadness, and tears increased. Overwhelming responses were triggered by unforeseen visual or auditory reminders of the person. Sleep disturbances began during end-stage care and continued after the death. At both times, caregiver grief was highly influenced by the social context; relationships with family and friends (more cohesive versus conflicted) shaped responses. Social work practitioners can help caregivers who may be unaware they are experiencing grief to identify and integrate these normal responses to loss.

At the eleventh hour: psychosocial dynamics in short hospice stays

PURPOSE

This study explored the psychosocial dynamics of short hospice stays (less than 2 weeks) of cancer patients age 65 and older.

DESIGN AND METHODS

In-depth interviews with 59 caregivers of 50 patients were audiotaped, transcribed, and coded by using Atlas ti software.

RESULTS

A descriptive typology is presented. A late diagnosis (n = 22 or 44%) was one in which cancer was diagnosed between 2 and 4 weeks before death, rendering earlier hospice admission impossible. Late diagnoses were made because the cancer was missed, masked by comorbidities, or the person resisted seeing a health care provider. A known diagnosis (n = 25 or 50%) was one in which the diagnosis was made long before hospice admission; admission was delayed because the person elected ongoing curative treatment until the final days of life, or the family managed the care without hospice until a turning point (medical, functional, pragmatic, or emotional) occurred, making the care unmanageable.

IMPLICATIONS

Hospice utilization is influenced by the interrelationship among patient-family-provider factors. Understanding the characteristics and needs of subgroups of terminally ill people is key to providing good care at life's end.

More than a set of teeth: assessing and enhancing dental students' perceptions of older adults

Dental professionals play a key role in maintaining the well-being of older adults by identifying problems that disturb systemic health. A 3-part instrument was used to assess dental students' knowledge of aging, comfort with patient diversity and patient care strategies (Years 1-4; N = 321). Collaborative education and services were developed by the Schools of Dental Medicine and Social Work. Results indicate that dental students' knowledge of aging was low (Palmore's FAQ 1 Range = 58%-64%), comfort with geriatric issues improved after the first year of intervention, and strategies for patient care changed with experience. Group differences suggest the importance of utilizing educational "turning points" as teachable moments.

Final transitions: family caregiving at the end of life

BACKGROUND

This study aimed to understand how caregivers make the transition to end-stage caregiving and to illuminate its unique aspects using a stress process model.

METHODS

Qualitative in-depth interviews were conducted with 74 caregivers of a family member who had been receiving hospice care for at least 2 weeks. Interviews were tape recorded, transcribed, and coded for emergent themes using constant comparative analysis.

RESULTS

End-stage caregiving was characterized in the sample as (1) comprehension of terminality (the interrelationship of information, physical and cognitive decline, and personality change and role losses), (2) near-acute care, (3) executive functions, and (4) final decision making. The comprehension of terminality emerged from three interrelated experiences: receiving and assimilating concrete information about the illness, observing the progression of the disease, and observing the personality change and role loss. The primary stressors (unique end-stage caregiving tasks) were providing near-acute care, assuming an executive function, and beginning and final decision making. The secondary stressors were family role conflict, work conflict, and financial strain. Resources, such as intrinsic and extrinsic religious and faith practices and social support, were identified. Negative outcomes included intense emotional responses, and positive outcomes included heightened development of meaning making.

CONCLUSION

The findings suggest that palliative care professionals have important opportunities to provide information and support to family caregivers during the final stages of the patient's terminal illness.

Improving patient retention and access to oral health care: the CARES program

Improving access to dental care for patients experiencing barriers such as financial, transportation, or mental health is a public health concern. Dental schools have an obligation to assist patients experiencing such barriers as well as to educate future dentists and allied professionals on how to assist these patients in overcoming barriers. Once admitted to the dental clinic, retention issues can further complicate the provision of dental care. This article will describe an innovative program designed to address biopsychosocial barriers to dental care. Needs assessments of patients sitting in the waiting room of the dental clinic were conducted by master's of social work (M.S.W.) students. Based on needs assessment results, common dental care barriers were identified and served as the foundation for the establishment of a social work program in the dental clinic. Dental students, faculty, and staff refer patients to the social work program when barriers to care are found. These biopsychosocial barriers are addressed by social workers, uniquely qualified professionals in providing case management, advocacy, referrals, education, and services (CARES). Over the course of three years, 80 percent of patients experiencing an identified barrier to the receipt of dental care were retained through social work intervention. These patients were able to receive dental care within the past year. Dental schools can collaborate with social work schools to establish a protocol and assistance program for dental patients experiencing difficulty accessing care, thereby improving oral health status, retention rates, and dental student education.

Understanding dental students' knowledge and perceptions of older people: toward a new model of geriatric dental education

Increasing numbers of older people and the decreasing rates of edentulism highlight the importance of dental education that focuses on oral health and aging. This evaluation study assessed dental students' knowledge and beliefs about older people as well as their awareness of the biopsychosocial concerns that are potential barriers to oral health care. Dental students' (N=202) knowledge and perceptions of older people were evaluated before and after the first year of a new educational program. Students completed the Palmore Facts on Aging Quiz II (FAQ II) and answered questions about health problems and social concerns that may influence patient care. The intervention was twofold: 1) the CARES (Counseling, Advocacy, Referral, Education, and Service) Program, a clinical collaboration between the schools of Dental Medicine and Social Work, was initiated; and 2) all students were exposed to geriatric educational interventions. FAQ II scores did not significantly change, but dental students' awareness of mental health, independence, and social concerns increased between Times 1 and 2. The results of the study suggest that positive interactions with older adults by health care providers may depend more on positive perceptions toward older people than increased knowledge about aging. Future research will focus on positive experiences with older adults and attitudes of dental students toward the elderly.

Understanding family responses to life-limiting illness: In-depth interviews with hospice patients and their family members

Understanding family dynamics is a key component in providing comprehensive care for persons with progressive illnesses and their caregivers. The purpose of this study was to investigate what families experience during an advancing illness and to describe their pattems of response. In-depth interviews (n=108) were conducted with families two weeks after hospice admission. Interviews were tape recorded, transcribed, and analyzed using qualitative methods. Six modes were distilled: reactive (illness generates intense responses), advocacy (vulnerability ignites assertive actions), fused (illness and decline are shared experiences), dissonant (diametrically opposed viewpoints cause struggle), resigned (decline and death are anticipated), and closed (outward responses are impassive). Three events triggered movement from one mode to another: (1) functional changes, (2) crisis events, and (3) provider communication. Providers who understand varied family reactions can ease the patient's suffering, assist relatives in providing effective care, and prepare them for the approaching death.

Life and death decisions: using school-based health education to facilitate family discussion about organ and tissue donation

Public education that encourages family discussions about organ and tissue donation can enhance understanding, facilitate a donor's wishes and increase the numbers of donations. Action research methods were used to explore the impact of a student-initiated family discussion about donation. Most discussions were positive; only 7% middle school and 4% high school participants described them as "terrible." "Getting it started" was the most difficult. High school students felt "very" or "somewhat" prepared, whereas middle school students only felt "somewhat prepared". Guided family discussions ensure that families have accurate information about donation and an opportunity to talk about end-of-life choices in a non-crisis situation.

Coexistent concerns: assessing the social and health needs of dental clinic patients

University dental clinic professionals identified increasing numbers of patients with complex problems and generated 2 research questions: (1) Are there significant health and social concerns within the dental clinic population that indicate the need for high-risk screening and social work services?; and (2) How do age, gender, and income influence health and social concerns in this population? This exploratory descriptive cross-sectional study employed a brief self-report survey in a clinic waiting area. Logistic regression was used to understand the influence of age, gender and income on the existence of specific concerns. Results indicate that caregiving, finances and health are issues for 1/3 of the participants and that 44% endorsed 2 or more concerns. These findings were used to develop a routine high-risk screening tool for dental clinic patients and social work services within the clinic; they suggest that community clinics with dental services are an important place for identifying complex unmet needs.