Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life

OBJECTIVE

An advance care directive is a legal document outlining the wishes made by a person about treatment options. However, there is increasing evidence that an advance care directive that has previously been documented may not always benefit the current prognosis of the patient. Therefore, the aim of the present study was to explore the experiences of Australian emergency doctors and nurses concerning the use of previously documented advance care directives at the point of care for patients and their families.

METHODS

A qualitative study guided by a phenomenological interpretive approach was employed. Semi-structured interviews were conducted with ED doctors and nurses across Australia. Data were thematically analysed using a seven-stage data analysis framework.

RESULTS

An analysis of the interview data resulted in four major themes: (i) Benefits of Advance Care Directives; (ii) Knowledge and Awareness; (iii) Communication; and (iv) Availability of Advance Care Directive Information.

CONCLUSIONS

From the findings, advance care directives were believed to be beneficial in decision making when patients, families, and ED staff agreed with the decisions made. Advance care directives were often made a long time ago but were useful to start conversations around goals of care and end-of-life care relevant to the patient's current situation. Findings in the present study further reinforced that an advance care directive was beneficial when used alongside goals of care at the point of care in EDs.

Nursing Informatics: Competency Challenges for Nursing Faculty

Nursing is the largest workforce in health care with nurses increasingly required to work with digital health technologies. However, despite the adoption of nursing informatics in Australia in the mid-1980s, nursing graduates are not being adequately equipped to use these technologies in a way that benefits the profession and improves patient care. Using a scoping review approach, this paper presents an analysis of contemporary published literature and describes the barriers to faculty engagement with digital health technologies in undergraduate nursing education. Thirty five articles were included and identified faculty lack of understanding of nursing informatics and resistance to technologies, limited infrastructure and expenditure, and limited educational resources and best practice recommendations as significant barriers to the integration of nursing informatics into undergraduate nursing curricula. Recommendations for faculty development will be explored.

Death, Dying, and End-of-Life Care Provision by Doctors and Nurses in the Emergency Department: A Phenomenological Study

There have been significant advancements in the fields of medicine, demography, and pathology. These disciplines have contributed to the classification and control of death and dying. People are now living longer with numerous comorbidities, and there is a significant aging population. Consequently, there have been increases in the numbers of people who present to emergency departments across Australia seeking access to care at the end of life. Emergency department staff must have the knowledge and skills required to provide end-of-life care in a setting that traditionally contradicts the goals of comfort care. With the increase in demand for end-of-life care in emergency departments, a gap exists in the experiences of how staff provide such care in this setting. As a result of this gap, it is important to understand the lived experiences of emergency department doctors and nurses who provide end-of-life care. The aim of this research is to understand the lived experiences of emergency department doctors and nurses concerning death, dying, and end-of-life care provision. Data were analyzed using Diekelmann's 7-step analysis to support Gadamer's phenomenological approach. Results indicate that challenges exist in the decision-making process of end-of-life care in emergency departments.

Defining Nursing Informatics: A Narrative Review

Healthcare has experienced rapid transformation with the development of digital technologies which aim to make healthcare safer and more efficient. In response, health informatics has evolved, including nursing informatics, which integrates nursing, information and communication technologies (ICT) and professional knowledge to improve patient outcomes. New language has developed to describe informatics and its processes; however, this has generally been poorly understood. This paper will describe current definitions of nursing informatics from three different healthcare contexts: Australia, the United States of America and Canada, to identify the similarities and differences between these definitions and to summarise the distinct bodies of knowledge described by each country. These countries have amongst the oldest definition attempts in the literature. A pragmatic approach was taken in this narrative review, working forward from historic references and backwards from recent references extracted from published health and nursing informatics literature.

Nurses' perceptions and experiences of caring for patients who die in the emergency department setting

INTRODUCTION

The number of people dying in emergency departments (EDs) is increasing. However, EDs are not well designed or resourced for safe and effective End-Of-Life (EOL) care encounters, and there is little evidence regarding clinicians' perceptions and experiences of providing such care when the death is sudden and unexpected.

AIM

This study explored nurses' perceptions and experiences of caring for patients who die suddenly and unexpectedly in the ED.

METHODS

Open-end responses were collected as part of a larger descriptive survey design. The qualitative data were analysed thematically.

RESULTS

211 ED nurse completed the online survey. Within the qualitative data, five themes were identified during analysis: 1) key elements of EOL care, 2) systemic and environmental barriers, 3) educational deficits, 4) role ambiguity, and 5) emotional impact. Participants identified communication, a standardised approach, and better educational preparedness as the most important elements of EOL care when the death was sudden and unexpected.

CONCLUSIONS

ED nurses want to provide high quality care to dying patients and their families. However, their efforts are hampered by systemic and environmental barriers outside their control. There is a need for a culture shift to overcome the barriers that currently obstruct ED nurses from providing meaningful and effective EOL care in the ED.

Nurses' experience of providing home-based palliative care in the country setting: An integrated literature review

AIMS

The aim of the study is to explore the experiences of nurses providing home-based palliative care for patients who live in country settings.

METHODS

This study is an integrated literature review. Electronic databases, specific journals of interest, and reference lists were searched using key words and Boolean operators. Descriptive thematic analysis was undertaken to identify main themes and subthemes. Critical appraisal of the articles was conducted using the qualitative Critical Appraisal Skills Program guidelines. Primary research articles published in English, in peer-reviewed journals from 1990 to 2017, were included.

RESULTS

Twelve articles were included in this review. Two main themes emerged including the nature of nursing in country communities and nurses' emotional responses. The first main theme had the subthemes of community connections, geographical distance and isolation, organizational deficits, lack of education, and resources. The second main theme consisted on five subthemes including feeling rewarded, autonomy and professional isolation, hope and hopelessness, frustration, and fear.

CONCLUSION

Literature is sparse reporting the lived experience of nurses providing palliative care in country areas for patients wanting to die at home. An increase in demand for a home-based palliative nursing service will require additional funding globally to meet this increase in the future.

Stigma and the in(visible) perspectives and expectations of home oxygen therapy among people with chronic breathlessness syndrome: A qualitative study

Background:

Chronic breathlessness syndrome in the context of advancing disease is distressing for all concerned. Oxygen is commonly prescribed in this setting; however, little is known about the perspectives of breathless people who either are on oxygen or are yet to have it prescribed.

Aim:

To understand and describe the perspectives and experiences of breathless people towards oxygen use at home.

Design:

This qualitative study utilised an interpretive description approach using semi-structured interviews and thematic analysis.

Setting/participants:

A total of 19 people with chronic breathlessness syndrome living in South Australia participated in semi-structured interviews. Participants were divided into sub-groups according to whether they were chronically breathless and (1) not using home oxygen ( n = 6), (2) using funded home oxygen for severe hypoxaemia ( n = 7) and (3) using home oxygen for palliation outside of funding guidelines ( n = 6).

Results:

Three main themes were identified: (1) managing distress and living with chronic breathlessness syndrome, with or without oxygen, requires a range of self-management strategies; (2) expectations of oxygen use: ‘Not as good as I thought it would be’; and (3) the stigma of using oxygen: the visible and invisible.

Conclusion:

People living with chronic breathlessness struggle daily with both the progression of the underlying disease and the distressing nature of the syndrome. While oxygen does provide benefit for some people, its use and the perceptions of its use are often associated with both the visible and invisible manifestations of stigma. Clinicians need to promote self-management strategies and give careful thought to the prescribing of home oxygen, especially outside the current funding guidelines.

Caregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study

CONTEXT

Despite limited clinical evidence, long-term oxygen therapy (LTOT) is used for the management of refractory breathlessness in people with life-limiting illnesses who are not necessarily hypoxemic.

OBJECTIVES

The aim of this study was to understand caregiver factors associated with caring for someone with LTOT from the perspectives and experiences of caregivers themselves.

METHODS

The qualitative study used semistructured interviews. The study was conducted in two states in Australia. Participants (n = 20) were self-nominated caregivers of people receiving LTOT for refractory breathlessness in the palliative setting.

RESULTS

Data analyses established one overarching theme titled: "Oxygen giveth (something to help caregivers relieve breathlessness) and oxygen taketh away (from patients who lose some autonomy)." The theme captured caregivers' feelings of extreme distress in response to witnessing refractory breathlessness, and oxygen fulfilling several critical and beneficial roles in this context. In parallel, caregivers also explicitly and implicitly articulated several downsides to the use of LTOT.

CONCLUSION

Caregivers find caring for someone with refractory breathlessness extremely distressing. The benefits of LTOT are often overestimated, whereas its potential harms are underestimated. As significant stakeholders of people receiving LTOT, caregivers should be provided with opportunities to collaborate with clinicians in evidence-based decision making, efforts should be made to provide them with information and education about the most effective pharmacological and nonpharmacological strategies to manage refractory breathlessness in a palliative care setting including the appropriate use of LTOT to enable them to do so.

Preliminary development and validation of a new end-of-life patient-reported outcome measure assessing the ability of patients to finalise their affairs at the end of life

Introduction

The ability of patients to finalise their affairs at the end of life is an often neglected aspect of quality of life (QOL) measurement in palliative care effectiveness research despite compelling evidence of the high value patients place on this domain.

Objective

This paper describes the preliminary development and evaluation of a new, single-item, end-of-life patient-reported outcome measure (EOLPRO) designed to capture changes in the ability of patients to finalise their affairs at the end of life.

Methods

Cognitive interviews with purposively sampled Australian palliative care patients (N = 9) were analysed thematically to explore content validity. Simultaneously, secondary analysis of data from a randomised controlled trial comparing ketamine and placebo for the management of cancer pain (N = 185) evaluated: construct validity; test-retest reliability; and responsiveness.

Results

Preliminary findings suggest patients interpret the new measure consistently. The EOLPRO captures the ability to complete physical tasks and finalise practical matters although it is unclear whether emotional tasks or resolution of relationship issues are considered. Personal and financial affairs should be separated to allow for differences in ability for these two types of affairs. The significant correlation between performance status and EOLPRO scores (r = 0.41, p<0.01, n = 137) and expected relationships between EOLPRO and proximity to death and constipation demonstrated construct validity. Pre- and post-treatment EOLPRO scores moderately agreed (n = 14, κ = 0.52 [95% CI 0.19, 0.84]) supporting reliability. The measure’s apparent lack of sensitivity to discriminate between treatment responders and non-responders may be confounded.

Conclusion

Based on the preliminary findings, the EOLPRO should be separated into ‘personal’ and ‘financial’ affairs with further testing suggested, particularly to verify coverage and responsiveness. Initial evaluation suggests that the single-item EOLPRO is a useful addition to QOL outcome measurement in palliative care effectiveness research because common palliative care specific QOL questionnaires do not include or explicitly capture this domain.

The clinical and social dimensions of prescribing palliative home oxygen for refractory dyspnea

BACKGROUND

Chronic breathlessness is a significant problem in palliative care and oxygen is often prescribed in an attempt to ameliorate it. Often, this prescription falls outside the current funding guidelines for long-term home oxygen use. The aim of this qualitative study was to understand the factors that most influence Australian specialist palliative care nurses' initiation of home oxygen for their patients.

METHODS

A series of focus groups were held across three states in Australia in 2011 involving specialist palliative care nurses. The invitation to the nurses was sent by e-mail through their national association. Recorded and transcribed data were coded for themes and subthemes. A summary, which included quotes, was provided to participants to confirm.

RESULTS

Fifty-one experienced palliative care nurses participated in seven focus groups held in three capital cities. Two major themes were identified: 1) logistic/health service issues (not reported in this paper as specific to the Australian context) involving the local context of prescribing and, 2) clinical care issues that involved assessing the patient's need for home oxygen and ongoing monitoring concerns. Palliative care nurses involved in initiating or prescribing oxygen often reported using oxygen as a second-line treatment after other interventions had been trialed and these had not provided sufficient symptomatic benefit. Safety issues were a universal concern and a person living alone did not emerge as a specific issue among the nurses interviewed.

CONCLUSION

The role of oxygen is currently seen as a second-line therapy in refractory dyspnea by specialist palliative care nurses.

Negotiating uncertain terrain: a qualitative analysis of clinicians' experiences of refractory suffering

In palliative care, the witnessing of unrelieved (refractory) suffering takes its toll on all concerned; however, the effect on experienced palliative clinicians of witnessing such suffering has largely been unexplored. The aim of this study was to examine health care professionals' (nurses, doctors, and allied health workers) experiences of working with a patient's refractory suffering, together with their clinical management strategies. A qualitative research design involving semistructured interviews and an online questionnaire was used to collect the data. Seventeen experienced palliative care clinicians participated; 13 with face-to-face interviews and a further 4 by an online questionnaire. The overarching theme of negotiating uncertain terrain was common across all clinician narratives. In order for them to work successfully with a patient's refractory suffering, the clinicians had to negotiate areas of practice characterized by uncertainty, with no clear directions and with few expert guides. In reviewing their experiences, they identified within an overarching theme of negotiating uncertain terrain four subthemes: Changing Approach from "Fixing" to "Being With," Maintaining Perspective, Negotiating and Maintaining Boundaries, and Living the Paradoxes. This study highlights that dealing with patients' refractory suffering involves clinicians moving into uncertain and unexplored territory. For them to work effectively in this terrain the clinicians need wisdom, courage, and a commitment to journeying alongside the suffering person.

Dyspnea management in palliative home care: a case series in malaysia

Managing dyspnea at home is a challenging task. Although a competent palliative home care team can assist a patient to live at home with better pain control, dyspnea is usually not as well managed. In the Asian context, there are few research studies in dyspnea management in palliative home care. This paper aims to illustrate the cultural context that has an impact on dyspnea management at home and the assessment and management of dyspnea in a community palliative care setting in Malaysia. This paper reports on a study of 5 dyspneic patients suffering from both cancer-related and non-cancer-related dyspnea. Its focus is on a unique Asian cultural belief system that affects communication about prognosis and the role of family in palliative home care. In addition, this paper also describes dyspnea assessment, the barriers to morphine use, benzodiazepine prescription, oxygen therapy, and nonpharmacologic intervention in this center.

Recent advances in the management of breathlessness

Breathlessness is a frightening symptom to both witness and experience. It is common in many conditions, especially in the palliative setting, profoundly affecting the quality of the person’s life. The purpose of this article is to provide an overview of the recent advances in the management of breathlessness in the areas of, knowledge of disease trajectories, assessment, pharmacological and non-pharmacological interventions and the use of oxygen.

Teaching palliative care across cultures: the singapore experience

Palliative care is a growing area of practice throughout the world and its promotion relies on adequately trained health care professionals. However, there are only a limited number of postgraduate academic courses or clinical training opportunities available, especially in resource challenged areas of the Asia Pacific region. This article outlines a creative endeavour between Flinders University, Adelaide Australia, the Singapore National Cancer Centre and the Asia Pacific Hospice and Palliative Care Network to provide an educational opportunity for students from the region. The strengths of the programme include its strong theoretical and evidenced-based framework, its multidisciplinary inclusiveness and its innovative and interactive teaching style. The main teaching challenge for the teaching team is to deliver culturally appropriate curricula to students from diverse cultural and linguistic backgrounds. This postgraduate programme is an important initiative for the region and for the development of future leaders and pioneers in the discipline.

Cancer and beyond: the question of survivorship

Today, more people are surviving cancer as a result of improved treatment and early diagnosis. In Australia, the 5-year survival rate for persons diagnosed with cancer is now approaching 50%. Although there is a growing population of cancer survivors, little is known about what surviving entails. Traditionally, a survivor has been defined as one who has been disease-free for more than 5 years. However, this definition does not take into account the experience nor the process of survival and the aim of this article is to document the process of surviving cancer as reflected in the experiences of cancer survivors. Using a method of hermeneutic phenomenology (as described by van Manen), the study draws on the stories of six women, who by their definition, are surviving cancer. A discussion of themes has been structured according to the everyday experiences of living in a body and living in time. The women describe a survival process that includes: 'feeling whole again'; 'the body as the house of suspicion'; 'the future in question'; 'changes in time'; 'lucky to be alive'; and 'sharing the journey'.