The wish to hasten death in patients with life-limiting conditions. A systematic overview

CONTEXT

A systematic review of the wish to hasten death among people with life-limiting conditions was published in 2011. Since then, other reviews and primary studies have been published that have added to knowledge regarding the conceptual definition, aetiology and assessment of the wish to hasten death.

OBJECTIVES

To provide an updated synthesis of the literature on the wish to hasten death in people with life-limiting conditions.

METHODS

An overview of systematic reviews and primary studies was conducted, using an integrative review method. PubMed, CINAHL, Scopus and Web of Science databases were searched, from their inception until 2023. We included all systematic reviews published to date and all primary studies not included in these systematic reviews.

RESULTS

Eleven systematic reviews and 35 primary studies were included. We propose that the phenomenon may usefully be considered as existing along a continuum, defined by the extent to which thoughts of dying are linked to action. A total of nine assessment tools have been described. The reported prevalence of the wish to hasten death appears to be influenced by the wording used in assessment instruments, as well as by the cut-off used when applying a particular tool. Depression, pain, functional disability, decreased sense of meaning in life, the sense of being a burden and reduced quality of life are the most widely reported related factors.

CONCLUSION

This overview underscores the need for clinical strategies that can identify different manifestations of the wish to hasten death among people with life-limiting conditions.

Definition and validation of the nursing diagnosis label "wish to die": a research protocol

BACKGROUND

Euthanasia has been incorporated into the health services of seven countries. The legalisation of these practices has important repercussions for the competences of nurses, and it raises questions about their role. When a patient with advanced disease expresses a wish to die, what is expected of nurses? What are the needs of these patients, and what kind of care plan do they require? What level of autonomy might nurses have when caring for these patients? The degree of autonomy that nurses might or should have when it comes to addressing such a wish and caring for these patients has yet to be defined. Recognising the wish to die as a nursing diagnosis would be an important step towards ensuring that these patients receive adequate nursing care. This study-protocol aims to define and validate the nursing diagnosis wish to die in patients with advanced disease, establishing its defining characteristics and related factors; to define nursing-specific interventions for this new diagnosis.

METHODS

A prospective three-phase study will be carried out. Phase-A) Foundational knowledge: an umbrella review of systematic reviews will be conducted; Phase-B) Definition and validation of the diagnostic nomenclature, defining characteristics and related factors by means of an expert panel, a Delphi study and application of Fehring's diagnostic content validation model; Phase-C) Definition of nursing-specific interventions for the new diagnosis. At least 200 academic and clinical nurses with expertise in the field of palliative care or primary health care will be recruited as participants across the three phases.

DISCUSSION

The definition of the wish to die as a nursing diagnosis would promote greater recognition and autonomy for nurses in the care of patients who express such a wish, providing an opportunity to alleviate underlying suffering through nursing-specific interventions and drawing attention to the needs of patients with advanced disease. The new diagnosis would be an addition to nursing science and would provide a framework for providing care to people with advanced disease who express such a wish. Nurses would gain professional autonomy about identifying, exploring and responding clinically to such a wish.

Episodic breathlessness in patients with cancer: definition, terminology, clinical features - integrative systematic review

PURPOSE

Breatlessness flares directly impair quality of life of patients with cancer. The aim of this review was to analyse and synthesise the available information related to its terminology, definition and clinical features in patients with cancer.

METHODS

Integrative systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in MEDLINE PubMed, CINAHLPlus, Web of Science, Cochrane Central Register Controlled Trials CENTRAL, Scopus and OpenAire.

RESULTS

Data from 1065 patients with cancer included in 12 studies were analysed. The preferred term for breathlessness flares was episodic dyspnoea (ED). The reported frequency of ED was 20.4% (70.9% in patients reporting background dyspnoea (BD)). ED intensity was moderate to severe with short duration (<10 min) in >80% of patients. The most common trigger was exertion (>90%) followed by emotional or environmental factors. ED management consisted mainly of pharmacological and non-pharmacological measures.

CONCLUSIONS

This systematic review shows that ED is common in patients with cancer, especially in those with BD. Further studies are urgently needed to better understand this condition and to develop specific therapeutic management.

PROSPERO REGISTRATION NUMBER

CRD42019126708.

Temporal validation of a risk prediction model for breast cancer-related lymphoedema in European population: A retrospective study

AIMS

To perform temporal validation of a risk prediction model for breast cancer-related lymphoedema in the European population.

DESIGN

Temporal validation of a previously developed prediction model using a new retrospective cohort of women who had undergone axillary lymph node dissection between June 2018 and June 2020.

METHODS

We reviewed clinical records to identify women who did and did not develop lymphoedema within 2 years of surgery and to gather data regarding the variables included in the prediction model. The model was calibrated by calculating Spearman's correlation between observed and expected cases. Its accuracy in discriminating between patients who did versus did not develop lymphoedema was assessed by calculating the area under the receiver operating characteristic curve (AUC).

RESULTS

The validation cohort comprised 154 women, 41 of whom developed lymphoedema within 2 years of surgery. The value of Spearman's coefficient indicated a strong correlation between observed and expected cases. Sensitivity of the model was higher than in the derivation cohort, as was the value of the AUC.

CONCLUSION

The model shows a good capacity to discriminate women at risk of lymphoedema and may therefore help in developing improved care pathways for individual patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Identifying risk factors for lymphoedema secondary to breast cancer treatment is vital given its impact on women's physical and emotional well-being.

IMPACT

What problem did the study address? Risk of BCRL. What were the main findings? The prediction model has a good capacity to discriminate women at risk of lymphoedema. Where and on whom will the research have an impact? In clinical practice with women at risk of BCRL.

REPORTING METHOD

STROBE checklist. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: It presents a validated risk prediction model for BCRL.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution in the conduct of this study.

Development of a Guide to Multidimensional Needs Assessment in the Palliative Care Initial Encounter (MAP)

CONTEXT

Ensuring patient-centered palliative care requires a comprehensive assessment of needs beginning in the initial encounter. However, there is no generally accepted guide for carrying out this multidimensional needs assessment as a first step in palliative intervention.

OBJECTIVES

To develop an expert panel-endorsed interview guide that would enable proactive and systematic Multidimensional needs Assessment in the Palliative care initial encounter (MAP).

METHODS

A preliminary version of the MAP guide was drafted based on a published literature review, published semistructured interviews with 20 patients, 20 family carers, and 20 palliative care professionals, and a nominal group process with palliative care professionals and a representative of the national patient's association. Consensus regarding its content was obtained through a modified Delphi process involving a panel of palliative care physicians from across Spain.

RESULTS

The published systematic literature review and qualitative study resulted in the identification of 55 needs, which were sorted and grouped by the nominal group. Following the Delphi process, the list of needs was reduced to 47, linked to six domains: Clinical history and medical conditions (n = 8), Physical symptoms (n = 17), Functional and cognitive status (n = 4), Psycho-emotional symptoms (n = 5), Social issues (n = 8), and Spiritual and existential concerns (n = 5).

CONCLUSION

MAP is an expert panel-endorsed semi-structured clinical interview guide for the comprehensive, systematic, and proactive initial assessment to efficiently assess multiple domains while adjusting to the needs of each patient. A future study will assess the feasibility of using the MAP guide within the timeframe of the palliative care initial encounter.

Validation of the Mexican version of the Schedule of Attitudes Toward Hastened Death in patients undergoing palliative care in Mexico

OBJECTIVES

The Schedule of Attitudes Toward Hastened Death (SAHD) has emerged as a valid and reliable tool to assess the wish to hasten death (WTHD) among patients diagnosed with advanced cancer; however, the instrument has never been culturally adapted and validated for patients in Mexico. This study sought to validate and abbreviate the SAHD tool for use among patients attending the Palliative Care Service of the Instituto Nacional de Cancerología in Mexico.

METHODS

The SAHD was culturally adapted from a previously published validation in patients from Spain. Eligible patients included Spanish literate subjects treated as outpatients in the Palliative Care Service, with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-3. Patients were asked to answer the Mexican version of SAHD (SAHD-Mx) instrument and the Brief Edinburgh Depression Scale (BEDS).

RESULTS

A total of 225 patients were included in the study. Median positive response in the SAHD-Mx was 2 (range 0-18). Positive correlation was identified between the SAHD-Mx scale and ECOG performance status (r = 0.188, p = 0.005), as well as BEDS (r = 0.567, p < 0.001). SAHD-Mx displayed strong internal consistency (alpha = 0.85) and adequate reliability from test-retest phone interviews (r = 0.567, p < 0.001). Using the confirmatory factor analysis model, a factor was identified and the number of items was reduced to 6, including items 4, 5, 9, 10, 13, and 18.

SIGNIFICANCE OF RESULTS

The SAHD-Mx emerges as an adequate tool, with appropriate psychometric characteristics, for assessing WTHD among patients diagnosed with cancer undergoing palliative care in Mexico. .

What makes the palliative care initial encounter meaningful? A descriptive study with patients with cancer, family carers and palliative care professionals

BACKGROUND

The palliative care initial encounter can have a positive impact on the quality of life of patients and family carers if it proves to be a meaningful experience. A better understanding of what makes the encounter meaningful would reinforce the provision of person-centred, quality palliative care.

AIM

To explore the expectations that patients with cancer, family carers and palliative care professionals have of this initial encounter.

DESIGN

Qualitative descriptive study with content analysis of transcripts from 60 semi-structured interviews.

SETTING/PARTICIPANTS

Twenty patients with cancer, 20 family carers and 20 palliative care professionals from 10 institutions across Spain.

RESULTS

Four themes were developed from the analysis of interviews: (1) the initial encounter as an opportunity to understand what palliative care entails; (2) individualised care; (3) professional commitment to the patient and family carers: present and future; and (4) acknowledgement.

CONCLUSION

The initial encounter becomes meaningful when it facilitates a shared understanding of what palliative care entails and acknowledgement of the needs and/or roles of patients with cancer, family carers and professionals. Further studies are required to explore how a perception of acknowledgement may best be fostered in the initial encounter.

Experiences of Isolation among Patients Hospitalized during an Infectious Disease Outbreak: A Systematic Review and Meta-Ethnography

Hospital isolation is common for people during infectious disease outbreaks. Anxiety, stress, depression and other psychosocial outcomes have been reported due to these measures. However, there is scarce evidence about the experience of being isolated and about best practices for empathic clinical care in these circumstances. The aim of this study was to explore the experience of isolation on patients hospitalized during an infectious disease outbreak. A systematic review and meta-ethnography was carried out. A search strategy was applied to the PubMed, CINAHL, Web of Science, and PsycINFO databases on April 14, 2021 and again May 2, 2022. Data synthesis was conducted using Noblit and Hare's method of qualitative thematic synthesis. Twenty reports were included in this review: 16 qualitative, two mixed-methods (only the qualitative part was analyzed), plus 2 personal view pieces. They described the experiences of a total of 337 people hospitalized and isolated with an infectious disease. Following analysis and coding of data, four themes emerged: 1) Feelings triggered by isolation; 2) Coping strategies; 3) Connection/disconnection; 4) Factors that influence the experience of isolation. Despite a sensitive search strategy, limited studies represent patient experiences using qualitative methods. The experience of isolation among patients hospitalized during an outbreak is characterized by fear, perceived stigma, and a sense of disconnection from others and the outside world due to a lack of information. Fostering a person-centered care model could help hospitalized patients develop adaptive mechanisms that minimize the impact of isolation.

Control in patients with advanced cancer: an interpretative phenomenological study

Background

In the context of life-threatening illness, loss of control is argued as a source of suffering and loss of perceived dignity, whereas having control over the dying process has been seen as a way of maintaining personal independence. Little is known about the meaning of control from the patients’ perspectives. Thus, the aim of this study was to explore how patients with advanced cancer understand control, in terms of underlying beliefs, attitudes, and expectations consistent with self-efficacy, in different dimensions of their life, their illness, and their healthcare.

Methods

We conducted semi-structured qualitative interviews using an interpretive phenomenological analysis approach. Patients with advanced cancer from an oncology unit and a palliative care unit from Barcelona (Spain) were recruited. The inclusion criteria were a) ≥ 18 years old; b) fluency in Spanish or Catalan; c) outpatients diagnosed with advanced cancer; d) Eastern Cooperative Oncology Group (ECOG) between 0 and 3; e) judged by their physician or nurse to be emotionally stable; f) considered to have control over their illness and circumstances according to their responsible physician; and g) signed informed consent.

Results

We interviewed eight participants (ages ranged from 29 to 70 years, six were female). Two themes were identified: 1) factors that influence the perception of control, with subthemes: uncertainty about future suffering, character traits underlying a need for control; sense of lack of care as a source of loss of control; and 2) perceiving control over an uncontrollable illness, explained by perceived control over subjective wellbeing and adjusting the focus of control. The data allowed us to identify strategies that promote a sense of control in these patients.

Conclusions

The illness, according to the participants, was experienced as series of losses. However, attention was often focused on areas where they continued to have control. These findings selectively reflect experiences of those who see themselves able to effect outcomes in life, suggesting future research should address how both family members and healthcare professionals can help to empower all patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00984-7.

Breast cancer-related lymphoedema: Risk factors and prediction model

AIMS

To identify the risk factors for lymphoedema following axillary lymph node dissection (ALND) in a European sample and to propose a lymphoedema prediction model for this population.

DESIGN

Predictive retrospective cohort study comparing women who developed lymphoedema in 2 years of undergoing ALND with those who did not developed lymphoedema.

METHODS

We reviewed the clinical records of 504 women who, between January 2008 and May 2018, underwent surgery for breast cancer that involved ALND. Logistic regression was used to identify significant risk factors for lymphoedema. The prediction accuracy of the model was assessed by calculating the area under the receiver operating characteristic curve.

RESULTS

Of the 504 women whose records were analysed, 156 developed lymphoedema. Significant predictors identified in the regression model were level of lymph node dissection, lymph node status, post-operative complications, body mass index (BMI) and number of lymph nodes extracted. The prediction model showed good sensitivity (80%) in the study population.

CONCLUSIONS

The factor contributing most to the risk of lymphoedema was the level of lymph node dissection, and the only patient-related factor in the prediction model was BMI. The model offers good predictive capacity in this population and it is a simple tool that breast care units could use to assess the risk of lymphoedema following ALND. Nurses with specialist knowledge of lymphoedema have a key role to play in ensuring that women receive holistic and individualized care.

IMPACT

What problem did the study address? Secondary lymphoedema is one of the main complications in the treatment of breast cancer. What were the main findings? The prediction model included five factors associated with the risk of lymphoedema following ALND. The strongest predictor was the level of lymph node dissection, and the only patient-related factor was BMI. Where and on whom will the research have an impact? The prediction model offers breast care units a tool for assessing the risk of lymphoedema in women undergoing surgery involving ALND. The results highlight the importance of weight reduction as a preventive measure and support a more conservative surgical approach.

Older Age: A Protective Factor Against Perceived Dignity-Related Distress in Patients With Advanced Cancer?

CONTEXT

Most older adults will face threats to loss of health and social support, which can affect their perceived dignity. Although problems with perceived dignity increase in the context of cancer, the specific experience for those older compared with younger patients with advanced cancer has not been described despite its contributions to the wish to hasten death (WTHD).

OBJECTIVES

To understand the influence of age group to the perception of dignity, considering changes in quality of life and the WTHD in patients with advanced cancer.

METHODS

The Patient Dignity Inventory was administered to 194 patients with advanced cancer. The data were analyzed by separating the sample into age groups younger than 65 years (N = 106) or 65 years and older (N = 88). Linear regression models were adjusted with the explanatory variables of WTHD, quality of life, as well as functional status, physical dependence, depression, anxiety, and sociodemographic variables.

RESULTS

Older patients showed a 2.6% decrease in the total scores of perceived dignity-related distress compared to younger patients.

CONCLUSION

Older age could be a protective factor against the perception of loss of dignity in patients with advanced cancer, a more positive perspective of the aging experience.

Effectiveness of a nurse-led, face-to-face health coaching intervention in enhancing activation and secondary outcomes of primary care users with chronic conditions

Prevalence of chronic diseases and multimorbidity is rising, and it remains unclear what the best strategy is for activating people with chronic conditions in their self-care. We designed a two-group quasi-experimental time series trial to examine the effectiveness of a nurse-led, face-to-face, individually-tailored health coaching (HC) intervention in improving patient activation and secondary outcomes (self-efficacy, quality of life, anxiety and depression symptoms, medication adherence, hospitalization and emergency visits) among primary care users with chronic conditions. A total of 118 people with chronic conditions were recruited through a primary care center and allocated to either the intervention group (IG) (n = 58) or control group (CG) (n = 60). The IG received a nurse-led individually-tailored HC intervention involving 4-6 face-to-face multicomponent sessions covering six core activation topics. The CG received usual primary care. Data were collected at baseline, after the intervention (6 weeks after baseline for controls) and at 6 and 12 months from baseline. Compared with controls, the IG had significantly higher patient activation scores after the intervention (73.29 vs. 66.51, p = .006). However, this improvement was not maintained at follow-up and there were no significant differences in secondary outcomes across the study period. HC may be an effective strategy for achieving short-term improvements in the activation of primary care users with chronic conditions. Further studies with different methodological approaches are needed to elucidate how HC may improve and sustain changes in patient activation.

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

Experiences and needs of nursing students during pandemic outbreaks: A systematic overview of the literature

Background

Recent epidemics have placed overwhelming demands on health systems, leading at times to the deployment of nursing students during the crisis. Little is known about the impact this experience has on students. Although studies have explored nursing students' knowledge about infection control, there are no specific recommendations regarding how these issues should be addressed in nurse education.

Purpose

To conduct a comprehensive systematic overview of the literature concerning nursing students in the context of emerging infectious disease epidemics or pandemics caused by zoonotic viruses.

Methods

Systematic overview.

Results

Forty-eight articles were included. Five themes were identified: education; knowledge, concern about risk and preventive behaviour; willingness to work during a pandemic outbreak; experiences and emotional impact; and ethical dilemmas.

Conclusions

There is a need to enhance nurse education to ensure that students have adequate education in infection prevention and control and the opportunity to develop the skills and attitudes required to provide care to infected patients during a pandemic. The outcomes of these education programmes would need to be evaluated using valid and reliable instruments so as to enable comparisons to be made to prepare future nurses to deal with new pandemics in an increasingly globalized world.

Screening for the Desire to Die in the First Palliative Care Encounter: A Proof-of-Concept Study

Context: There is a lack of consensus about the appropriate moment to assess a potential wish to hasten death (WTHD) in patients with life-threatening illness, despite evidence of its positive appraisal among patients. Objectives: To evaluate the practical potential and acceptability of questions about the WTHD in the first palliative care (PC) clinical encounter. Design: A proof-of-concept single-arm unmasked trial. Subjects: We enrolled 30 advanced cancer patients, 16 inpatients and 14 outpatients in their first PC clinical encounter. Measurements: We assessed the WTHD using a semistructured interview guide, the Assessment of the Frequency and Extent of the Desire to Die (AFEDD) embedded in a multidimensional needs assessment carried out during the first PC encounter. Information about practical potential [patients consider the assessment (a) important and (b) helpful] and acceptability [patients (a) understand and (b) are not bothered by the questions] was obtained. Results: Thirty-two patients were approached and 30 (94%) agreed to participate. The WTHD was present in two outpatients and eight inpatients. The question to assess WTHD were well understood by 94% of patients and was considered not bothersome by 87% and quite or very helpful by 80%, regardless of whether they had WTHD. Conclusions: The results support that clinicians can integrate screening for the WTHD in usual clinical practice within a multidimensional needs assessment. Patient acceptability suggests that this as a part of patient-centered care including in the first PC clinical encounter. Further studies are needed to confirm efficacy and safety in larger and different populations.

Health-related quality of life in patients with advanced cancer who express a wish to hasten death: A comparative study

BACKGROUND

Some evidence suggests the wish to hasten death is related to poor health-related quality of life. Deficits in perceived dignity and self-efficacy are risk factors for wish to hasten death that also impact health-related quality of life.

AIM

To compare perceived health-related quality of life, dignity and self-efficacy in patients with advanced cancer who either do (case group) or do not (control group) express a wish to hasten death. Cases and controls were matched on sociodemographic and functional characteristics.

DESIGN

A comparative cross-sectional study.

PARTICIPANTS

A total of 153 adult patients with advanced cancer were assessed for wish to hasten death using the Desire for Death Rating Scale. Scores ⩾1 indicate some degree of wish to hasten death (case group, n = 51), and score = 0 implies no wish to hasten death (control group, n = 102). Assessments included health-related quality of life using the European Organization for Research and Treatment of Cancer Quality-of-Life Core 15-Item Palliative Questionnaire, perceived loss of dignity using the Patient Dignity Inventory and self-efficacy using the General Self-Efficacy Scale.

RESULTS

Patients with a wish to hasten death had worse emotional functioning (p < 0.001), greater perceived loss of dignity (p < 0.001) and lower self-efficacy (p = 0.001). There was no difference in most physical symptoms. Perceived overall health-related quality of life was significantly worse for those with a clinically relevant wish to hasten death (p = 0.023) and marginally worse for the case group than the control group (p = 0.052).

CONCLUSION

Patients with wish to hasten death showed lower perceived dignity, self-efficacy and emotional quality of life than patients without wish to hasten death without necessarily perceiving worse physical symptoms.

Proactive and systematic multidimensional needs assessment in patients with advanced cancer approaching palliative care: a study protocol

INTRODUCTION

The benefits of palliative care rely on how healthcare professionals assess patients' needs in the initial encounter/s; crucial to the design of a personalised therapeutic plan. However, there is currently no evidence-based guideline to perform this needs assessment. We aim to design and evaluate a proactive and systematic method for the needs assessment using quality guidelines for developing complex interventions. This will involve patients, their relatives and healthcare professionals in all phases of the study and its communication to offer clinical practice a reliable approach to address the palliative needs of patients.

METHODS AND ANALYSIS

To design and assess the feasibility of an evidence-based, proactive and systematic Multidimensional needs Assessment in Palliative care (MAP) as a semistructured clinical interview guide for initial palliative care encounter/s in patients with advanced cancer. This is a two-phase multisite project conducted over 36 months between May 2019 and May 2022. Phase I includes a systematic review, discussions with stakeholders and Delphi consensus. The evidence gathered from phase I will be the basis for the initial versions of the MAP, then submitted to Delphi consensus to develop a preliminary guide of the MAP for the training of clinicians in the feasibility phase. Phase II is a mixed-methods multicenter feasibility study that will assess the MAP's acceptability, participation, practicality, adaptation and implementation. A nested qualitative study will purposively sample a subset of participants to add preliminary clues about the benefits and barriers of the MAP. The evidence gathered from phase II will build a MAP user guide and educational programme for use in clinical practice.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the university research ethics committee where the study will be carried out (approval reference MED-2018-10). Dissemination will be informed by the results obtained and communication will occur throughout.

The clinical evaluation of the wish to hasten death is not upsetting for advanced cancer patients: A cross-sectional study

BACKGROUND

An important concern of healthcare professionals when exploring the wish to hasten death with patients is the risk of causing them some type of distress.

AIM

To assess the opinion of hospitalized patients with advanced cancer about the proactive assessment of the wish to hasten death.

DESIGN

Descriptive, cross-sectional study.

SETTING/PARTICIPANTS

We assessed 193 advanced cancer patients admitted to an oncology ward for the wish to hasten death using a semi-structured clinical interview. After the assessment the participants were surveyed to determine whether they found the interview upsetting and, if so to what extent, and also their opinion regarding the assessment's importance.

RESULTS

The wish to hasten death was reported by 46 (23.8%) patients. The majority of patients (94.8%) did not find talking about the wish to hasten death to be upsetting, regardless of whether they presented it or not. The majority of patients (79.3%) considered that it was either quite or extremely important for the clinician to proactively assess the wish to hasten death and discuss this topic, regardless of whether they experienced it.

CONCLUSIONS

In this study, most of the advanced cancer patients did not find the assessment of wish to hasten death to be upsetting, and a substantial proportion of patients in this study believe that it is important to routinely evaluate it in this setting. These findings suggest that healthcare professionals can explore the wish to hasten death proactively in routine clinical practice without fear of upsetting patients.

The experiences and needs of primary family caregivers of patients with multiple myeloma: A qualitative analysis

BACKGROUND

Family caregivers play a key role in the lives of patients with multiple myeloma. However, very little is known about the impact that the disease (its diagnosis, course and prognosis) has on the main family caregiver.

AIM

To achieve a deeper understanding of the lived experience of individuals who are the primary caregiver of a relative with multiple myeloma and to shed light on their needs.

DESIGN

Interpretative phenomenological study.

SETTING AND PARTICIPANTS

A total of 12 individuals who were the main family caregivers of a relative with multiple myeloma who was under outpatient follow-up at a cancer unit in Barcelona were recruited via purposive sampling until data saturation was reached. In semi-structured in-depth interviews, participants described their experiences of caring for their relative with multiple myeloma. Interviews were recorded, transcribed and analysed using ATLAS.ti v7.2. The seven steps proposed by Colaizzi were used for data analysis, and the relationships among emerging themes were examined.

FINDINGS

Four main themes emerged: (a) a new life, adapting to the disease, (b) commitment to the patient, (c) the emotional sphere and (d) experiences in relation to the care and support received. The analysis also revealed a core overarching theme: uncertainty.

CONCLUSION

Primary family caregivers experienced intense uncertainty, and they described a strong need to air their feelings. Specific practical initiatives, targeting both health-related and logistical aspects of care, need to be developed in order to support family caregivers of myeloma patients.

Feeling like a burden to others and the wish to hasten death in patients with advanced illness: A systematic review

Studies that have explored the wish to hasten death (WTHD) in patients with advanced illness have found that the feeling of being a burden may trigger WTHD. Research suggests that both the feeling and the wish are indicators of multidimensional suffering whose meaning may depend on the patient's biographical background. Therefore, we carried out a systematic review and meta-ethnography. Fourteen qualitative studies, reported in 16 articles, met the inclusion criteria. The analysis identified two themes: the personal and social dimensions that could help to explain the feeling of being a burden in these patients. These dimensions reveal how this feeling is linked to physical, psychological/emotional, existential and social factors. The feeling of being a burden cannot be understood without considering patients' personal interpretation of their dependency or care needs, and hence it is also necessary to understand their biographical background. Such an understanding is crucial to inform clinical policies based on the moral duty to provide all patients with humane care.

[Emergence of the nursing model transmitted in Spanish universities: an analytical approach through Grounded Theory]

The scope of this paper was to ascertain the meaning of the term "nursing" among teaching nurses at Spanish universities. The research was qualitative, and the strategy used was analytical induction. Sampling was theoretical and focused on the selection of extreme cases and the data collection technique was in-depth interviews. The analysis was carried out using the specific Grounded Theory technique. Strategies were established to ensure credibility, portability, confirmability and auditability. Based on the analysis of the data, three categories were identified that responded to the planned objective: it is a "human activity linked to motherhood," a "vocation to help others that some people have" and an "activity that takes care of the needs of others respecting their identity." It can be concluded that in Spanish universities a model of nurse is being transmitted where the proper role of care is inherent to the feminine gender and the vocation of service to others that some people have. This is the reason why the Spanish Royal Academy (RAE) only identifies the role of technical assistance to medicine as a professional element of nursing.

Assessing the competences associated with a nursing Bachelor thesis by means of rubrics

BACKGROUND

Writing a Bachelor thesis is the last step in obtaining a university degree. The thesis may be job- or research-orientated, but it must demonstrate certain degree-level competences. Rubrics are a useful way of unifying the assessment criteria.

OBJECTIVES

To design a system of rubrics for assessing the competences associated with the Bachelor thesis of a nursing degree, to examine the system's reliability and validity and to analyse results in relation to the final thesis mark.

DESIGN

Cross-sectional and psychometric study conducted between 2012 and 2014.

SETTINGS

Nursing degree at a Spanish university.

PARTICIPANTS

Twelve tutors who designed the system of rubrics. Students (n = 76) who wrote their Bachelor thesis during the 2013-2014 academic year.

METHODS

After deciding which aspects would be assessed, who would assess them and when, the tutors developed seven rubrics (drafting process, assessment of the written thesis by the supervisor and by a panel, student self-assessment, peer assessment, tutor evaluation of the peer assessment and panel assessment of the viva). We analysed the reliability (inter-rater and internal consistency) and validity (convergent and discriminant) of the rubrics, and also the relationship between the competences assessed and the final thesis mark.

RESULTS

All the rubrics had internal consistency coefficients >0.80. The rubric for oral communication skills (viva) yielded inter-rater reliability of 0.95. Factor analysis indicated a unidimensional structure for all but one of the rubrics, the exception being the rubric for peer assessment, which had a two-factor structure. The main competences associated with a good quality Bachelor thesis were written communication skills and the ability to work independently.

CONCLUSION

The assessment system based on seven rubrics is shown to be valid and reliable. Writing a Bachelor thesis requires a range of degree-level competences and it offers nursing students the opportunity to develop their evidence-based practice skills.

Correction: An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

[This corrects the article DOI: 10.1371/journal.pone.0146184.].

Ethical Challenges for an Understanding of Suffering: Voluntary Stopping of Eating and Drinking and the Wish to Hasten Death in Advanced Patients

Some persons with advanced disease but no significant cognitive impairments consciously decide to stop taking food and fluids orally, even though they remain physically able to do so. The question is to what extent voluntarily stopping eating and drinking (VSED) may be considered an expression of a wish to hasten death, in the sense that the latter has been defined recently. We analyze the data reported in some studies in relation to primary care patients who died as a result of VSED and examine their results in light of the qualitative findings of patients that expressed a wish to die. In our view, VSED can be understood as a response to physical/psychological/spiritual suffering, as an expression of a loss of self, a desire to live but not in this way, a way of ending suffering, and as a kind of control over one’s life. Thus, VSED is consistent with the wish to hasten death. Prior to interpreting this act as a deliberate expression of personal autonomy, it is important to explore all possible areas of suffering, including physical symptoms, psychological distress, existential suffering, and social aspects. Failure to do so will mean that we run the risk of abandoning a fellow human being to his or her suffering.

Palliative care in patients with haematological neoplasms: An integrative systematic review

BACKGROUND

Palliative care was originally intended for patients with non-haematological neoplasms and relatively few studies have assessed palliative care in patients with haematological malignancies.

AIM

To assess palliative care interventions in managing haematological malignancies patients treated by onco-haematology departments.

DESIGN

Integrative systematic review with data extraction and narrative synthesis (PROSPERO #: CRD42016036240).

DATA SOURCES

PubMed, CINAHL, Cochrane, Scopus and Web-of-Science were searched for articles published through 30 June 2015. Study inclusion criteria were as follows: (1) published in English or Spanish and (2) containing data on palliative care interventions in adults with haematological malignancies.

RESULTS

The search yielded 418 articles; 99 met the inclusion criteria. Six themes were identified: (1) end-of-life care, (2) the relationship between onco-haematology and palliative care departments and referral characteristics, (3) clinical characteristics, (4) experience of patients/families, (5) home care and (6) other themes grouped together as 'miscellany'. Our findings indicate that palliative care is often limited to the end-of-life phase, with late referral to palliative care. The symptom burden in haematological malignancies patients is more than the burden in non-haematological neoplasms patients. Patients and families are generally satisfied with palliative care. Home care is seldom used. Tools to predict survival in this patient population are lacking.

CONCLUSION

Despite a growing interest in palliative care for haematological malignancies patients, the evidence base needs to be strengthened to expand our knowledge about palliative care in this patient group. The results of this review support the need to develop closer cooperation and communication between the palliative care and onco-haematology departments to improve patient care.

Meaning in Life as a Mediator Between Physical Impairment and the Wish to Hasten Death in Patients With Advanced Cancer

CONTEXT

Meaning in life (MiL) is a key factor for ensuring spiritual well-being and quality of life among patients with life-threatening illnesses. However, the role of MiL in relation to the wish to hasten death (WTHD) and its interaction with other physical and psychological factors in patients with advanced cancer has not yet been studied.

OBJECTIVE

The objective of this study was to analyze the relationship between the WTHD and MiL and to propose a theoretical model of functional relationships among WTHD, performance status, depression, and MiL.

METHODS

This is a cross-sectional study of 101 patients in a palliative care unit, who were assessed in the context of a clinical interview. Outcome measures included performance status, depression, MiL, and the WTHD. Structural equation modeling was used to analyze the functional relationships between these factors.

RESULTS

The WTHD correlated significantly (P < 0.01) with MiL (r = 0.60), performance status (r = 0.548), and depression (r = 0.397). The structural equation modeling analysis showed that although there was no significant direct effect between performance status and the WTHD, there was a significant total effect because of the mediation of depression and MiL. The latter played the most significant role, accounting for 76.5% of the mediation.

CONCLUSION

These results support the proposed model and provide evidence of a mediator effect of MiL and depression on the relationship between physical impairment and the WTHD in advanced patients. Our findings suggest that interventions to enhance MiL could help to address and/or prevent the emergence of a WTHD in this population.

Understanding meaning in life interventions in patients with advanced disease: A systematic review and realist synthesis

BACKGROUND

Among patients with advanced disease, meaning in life is thought to enhance well-being, promote coping and improve the tolerance of physical symptoms. It may also act as a buffer against depression and hopelessness. As yet, there has been no synthesis of meaning in life interventions in which contextual factors, procedures and outcomes are described and evaluated.

AIMS

To identify meaning in life interventions implemented in patients with advanced disease and to describe their context, mechanisms and outcomes.

DESIGN

Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and realist synthesis of meaning in life interventions using criteria from the Realist And Meta-narrative Evidence Syntheses: Evolving Standards project.

DATA SOURCES

The CINAHL, PsycINFO, PubMed and Web of Science databases were searched.

RESULTS

A total of 12 articles were included in the systematic review, corresponding to nine different interventions. Five articles described randomized controlled trials, two were qualitative studies, two were commentaries or reflections, and there was one pre-post evaluation, one exploratory study and one description of a model of care. Analysis of context, mechanisms and outcomes configurations showed that a core component of all the interventions was the interpersonal encounter between patient and therapist, in which sources of meaning were explored and a sense of connectedness was re-established. Meaning in life interventions were associated with clinical benefits on measures of purpose-in-life, quality of life, spiritual well-being, self-efficacy, optimism, distress, hopelessness, anxiety, depression and wish to hasten death.

CONCLUSION

This review provides an explanatory model of the contextual factors and mechanisms that may be involved in promoting meaning in life. These approaches could provide useful tools for relieving existential suffering at the end of life.

Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography

OBJECTIVES

Patients with advanced disease sometimes express a wish to hasten death (WTHD). In 2012, we published a systematic review and meta-ethnography of qualitative studies examining the experience and meaning of this phenomenon. Since then, new studies eligible for inclusion have been reported, including in Europe, a region not previously featured, and specifically in countries with different legal frameworks for euthanasia and assisted suicide. The aim of the present study was to update our previous review by including new research and to conduct a new analysis of available data on this topic.

SETTING

Eligible studies originated from Australia, Canada, China, Germany, The Netherlands, Switzerland, Thailand and USA.

PARTICIPANTS

Studies of patients with life-threatening conditions that had expressed the WTHD.

DESIGN

The search strategy combined subject terms with free-text searching of PubMed MEDLINE, Web of Science, CINAHL and PsycInfo. The qualitative synthesis followed the methodology described by Noblit and Hare, using the 'adding to and revising the original' model for updating a meta-ethnography, proposed by France et al. Quality assessment was done using the Critical Appraisal Skills Programme checklist.

RESULTS

14 studies involving 255 participants with life-threatening illnesses were identified. Five themes emerged from the analysis: suffering (overarching theme), reasons for and meanings and functions of the WTHD and the experience of a timeline towards dying and death. In the context of advanced disease, the WTHD emerges as a reaction to physical, psychological, social and existential suffering, all of which impacts on the patient's sense of self, of dignity and meaning in life.

CONCLUSIONS

The WTHD can hold different meanings for each individual-serving functions other than to communicate a genuine wish to die. Understanding the reasons for, and meanings and functions of, the WTHD is crucial for drawing up and implementing care plans to meet the needs of individual patients.

Adaptation to European Spanish and psychometric properties of the Patient Activation Measure 13 in patients with chronic diseases

BACKGROUND

The 13-item Patient Activation Measure (PAM-13) is an instrument that assesses people's knowledge, skills and confidence for self-management of their health and health care. Scores on the PAM-13 have been shown to predict adherence to health behaviours, health-related outcomes and health care costs.

OBJECTIVES

To develop a European Spanish adaptation of the original PAM-13 and to examine its psychometric properties in a sample of chronic patients.

METHODS

The PAM-13 was forward-backward translated and then completed by chronic patients attending a primary health care centre. Data were analysed with a Rasch model. We assessed the functioning of the rating scale, its reliability, the item goodness-of-fit, differential item functioning (DIF), local dependence, unidimensionality and correlation analysis.

RESULTS

A total of 208 patients (80%) completed the questionnaire. Data showed a fit to the Rasch model. More than 50% of patients endorsed all the items. Item rank for the Spanish sample was similar to the original, with few differences. We found significant differences (P < 0.05) in PAM-13 measures according to adherence to prescribed medicines and positive correlations with self-efficacy and physical quality of life.

CONCLUSIONS

The European Spanish PAM-13 is a reliable and valid instrument for assessing activation in patients with chronic disease in Spain. We suggest adding new items to the instrument so as to examine patients with higher activation levels in the future. Further studies are needed to evaluate the usefulness of this new Spanish PAM-13 in different settings and populations, as well as to examine the relationship between PAM-13 scores and other health-related outcomes.

Transfer of nurse education to universities under a model of person-centred care: A consequence of changes in Spanish society during the democratic transition

BACKGROUND

In Spain the transfer of nurse education to universities was accompanied by a shift towards a model of person-centred care.

AIM

To explore whether the change in nurses' professional profile (from physician assistant to providers of person-centred care) was a response to changing needs in Spanish society.

DESIGN

Qualitative study.

METHODS

Theoretical sampling and in-depth interviews using an inductive analytical approach.

RESULTS

Four categories described the nursing profession in Spain prior to the introduction of university training: the era of medical assistants; technologisation of hospitals; personal care of the patient based on Christian values; professional socialisation differentiated by gender. Further analysis showed that these categories could be subsumed under a broader core category: the transfer of nurse education to universities as part of Spain's transition to democracy.

CONCLUSION

The transfer of nurse education to universities was one of several changes occurring in Spanish society during the country's transition to democratic government. The redefined public health system required a highly skilled workforce, with improved employment rights being given to female health professionals, notably nurses.

Professional responsibility and decision-making in the context of a disease-focused model of nursing care: The difficulties experienced by Spanish nurses

When, in 1977, nurse education in Spain was transferred to universities a more patient-centred, the Anglo-American philosophy of care was introduced into a context in which nurses had traditionally prioritised their technical skills. This paper examines the characteristics of the nurse's professional role in Spain, where the model of nursing practice has historically placed them in a position akin to that of physician assistants. The study design was qualitative and used the method of analytic induction. Participants were selected by means of theoretical sampling and then underwent in-depth interviews. The resulting material was analysed using an approach based on the principles of grounded theory. Strategies were applied to ensure the credibility, transferability, dependability and confirmability of the findings. The main conclusion is that nurses in Spain continue to work within a disease-focused model of care, making it difficult for them to take responsibility for decision-making.

Assessment of the wish to hasten death in patients with advanced disease: A systematic review of measurement instruments

BACKGROUND

Patients with advanced conditions may present a wish to hasten death. Assessing this wish is complex due to the nature of the phenomenon and the difficulty of conceptualising it.

AIM

To identify and analyse existing instruments for assessing the wish to hasten death and to rate their reported psychometric properties.

DESIGN

Systematic review based on PRISMA guidelines. The COnsensus-based Standards for the selection of health Measurement INstruments checklist was used to evaluate the methodological quality of validation studies and the measurement properties of the instrument described.

DATA SOURCES

The CINAHL, PsycINFO, Pubmed and Web of Science databases were searched from inception to November 2015.

RESULTS

A total of 50 articles involving assessment of the wish to hasten death were included. Eight concerned instrument validation and were evaluated using COnsensus-based Standards for the selection of health Measurement INstruments criteria. They reported data for between two and seven measurement properties, with ratings between fair and excellent. Of the seven instruments identified, the Desire for Death Rating Scale or the Schedule of Attitudes toward Hastened Death feature in 48 of the 50 articles. The Schedule of Attitudes toward Hastened Death is the most widely used and is the instrument whose psychometric properties have been most often analysed. Versions of the Schedule of Attitudes toward Hastened Death are available in five languages other than the original English.

CONCLUSION

This systematic review has analysed existing instruments for assessing the wish to hasten death. It has also explored the methodological quality of studies that have examined the measurement properties of these instruments and offers ratings of the reported properties. These results will be useful to clinicians and researchers with an interest in a phenomenon of considerable relevance to advanced patients.

Spanish Adaptation of the Frommelt Attitude Toward Care of the Dying Scale (FATCOD-S) in Nursing Undergraduates

The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) is designed to assess the attitudes of professionals and trainees toward caring for the dying patient and their family members. In this study the main aim is to adapt the FATCOD to a Spanish context (FATCOD-S). In addition, the relations between FATCOD-S, sociodemographic variables, emotional intelligence, and death attitudes have been analyzed. A sample of 669 Spanish nursing students from four Universities responded to a questionnaire. The exploratory factor analysis (EFA) concludes a structure composed of two significant factors. A confirmatory factor analysis (CFA) was carried out. The CFA supported a two-factor model. Students with past experience of death and those who had received training in palliative care scored significantly higher on both factors of the FATCOD-S ( p < 0.01). The FATCOD-S is an effective and valid tool for measuring the attitudes of Spanish nursing students toward caring for patients at the end of life.

Development of a short form of the Spanish schedule of attitudes toward hastened death in a palliative care population

PURPOSE

The schedule of attitudes toward hastened death (SAHD) is widely used to assess the wish to hasten death (WTHD) among patients with life-threatening conditions. A short form of the SAHD would increase its clinical applicability in this population.

METHOD

Rasch analysis of data from 101 Spanish palliative inpatients. Item reduction involved selecting items with a high discrimination index (point-biserials ≥0.70), removing items with inadequate fit statistics, and assessing unidimensionality and local dependency. We examined the test probability function to establish an empirical risk score for suffering a WTHD and tested convergence between the original and the reduced set of items.

RESULTS

A set of five items met all quality criteria. In this sample, 20.8 % of participants had a higher risk of a WTHD (p > 50 %) at a score of 3. Correlation analysis confirmed convergent validity between the original and reduced forms. Concurrent validity was confirmed by the similar correlations shown by both versions of the SAHD (5 and 20 items) with other measures.

CONCLUSION

This 5-item Spanish form of the SAHD could be a suitable alternative to the full instrument. The cut-off score derived from the Rasch analysis may be able to detect patients at risk of a WTHD.

Patient Perspectives of Dignity, Autonomy and Control at the End of Life: Systematic Review and Meta-Ethnography

BACKGROUND

Research in the end-of-life context has explored the sense of dignity experienced by patients with advanced disease, examining the factors associated with it. Whereas certain perspectives regard dignity as an intrinsic quality, independent of external factors, in the clinical setting it is generally equated with the person's sense of autonomy and control, and it appears to be related to patients' quality of life. This study aims to explore the relationship between perceived dignity, autonomy and sense of control in patients at the end of life.

METHODS

We conducted a systematic review and meta-ethnography using reciprocal translation and line-of-argument synthesis. The search strategy used MeSH terms in combination with free-text searching of the Pubmed, Web of Science, CINAHL, PsycINFO and Cochrane databases, from their inception until 2015. This identified 186 articles, after excluding duplicates. The inclusion criterion was primary qualitative studies in which dignity, autonomy and control at the end of life were explored. Studies were evaluated using the CASP guidelines.

RESULTS

Twenty-one studies recording the experiences of 400 participants were identified. Three themes emerged: a) dignity mediated by the loss of functionality, linked to the loss of control; b) dignity as identity; and c) autonomy as a determining factor of perceived dignity, understood as the desire for control over the dying process and the desire for self-determination. We propose an explanatory model which highlights that those patients with an intrinsic sense of dignity maintained a positive view of themselves in the face of their illness.

CONCLUSION

This synthesis illustrates how dignity and autonomy are intertwined and can be perceived as a multidimensional concept, one that is close to the notion of personal identity. The ability to regard dignity as an intrinsic quality has a positive impact on patients, and the design of care strategies should take this into account.

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

BACKGROUND

The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD.

METHODS

Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy.

FINDINGS

All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD.

CONCLUSIONS

This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.

What Gives Meaning in Life to Patients With Advanced Cancer? A Comparison Between Spanish, German, and Swiss Patients

CONTEXT

Meaning in life (MiL) is a construct that varies across individuals, situations, cultures, and countries, and protects against emotional distress at the end of life.

OBJECTIVES

To examine MiL in inpatients with advanced cancer from Barcelona, Spain, and to compare the findings with those obtained in German and Swiss samples.

METHODS

This was a cross-sectional study in which the Schedule for Meaning in Life Evaluation (SMiLE) was administered. The SMiLE asks respondents to list individual areas that give meaning in their lives and then to rate their current level of importance and satisfaction with the listed areas.

RESULTS

A total of 101 inpatients completed the SMiLE. The Index of Satisfaction was 76.8 ± 21.1, the Index of Weighting was 88.0 ± 13.0, and the Index of Weighted Satisfaction was 76.9 ± 20.7. Family, partnership, well-being, and friends were the four areas listed by the largest proportion of Spanish patients. Compared with the German sample, Spanish patients were more likely to list well-being (P < 0.01) and pleasure (P < 0.05) and less likely to list animals/nature, leisure time, and finances (P < 0.01). With respect to their Swiss counterparts, Spanish patients were more likely to list health (P < 0.01) and less likely to list friends, leisure time, animals/nature, and finances (P < 0.01).

CONCLUSION

Differences were identified in the areas of MiL listed by the participants according to country of origin. Compared with their German and Swiss counterparts, the Spanish patients listed more areas involving interpersonal relationships. Interpersonal relationships, at both the family and wider social level, are reported to be the areas that give the greatest MiL to these patients. These aspects, therefore, should be considered when drawing up care plans designed to help patients achieve the maximum possible comfort and quality of life.