Need of community-based palliative care in rural India and factors that influence its sustainability: a comprehensive exploration using qualitative methodology in rural Puducherry, India

Background

The existing palliative care services in India are concentrated in urban areas, attached to tertiary care hospitals. This poses issues relating to access and equity for people in rural locations and with low socioeconomic status. A Community-Based Palliative Care (CBPC) service named Sanjeevan has been initiated in Puducherry, a union territory of India to provide physical, social, psychological, and emotional support to incurably ill people, including older adults living in rural areas.

Objectives

To understand the social mechanisms that underpin the implementation of CBPC in rural parts of India and the challenges to its sustainability.

Design

Qualitative research using focus group discussions (FGDs) and key informant interviews (KIIs).

Methods

Community-based participatory research (CBPR) approach was used in this study, and descriptive analysis was done. Through CBPR it was possible to document and interpret local knowledge on the community concerns and assets along with the experiences of the community members. Purposive sampling was used to identify vocal participants involved in patient care and areas of the Sanjeevan program such as financial management, administration, and community mobilization. Seven KIIs and four FGDs were conducted, with 7-8 participants in each.

Results

The analysis indicated the need for a CBPC and the factors enabling its establishment. The findings revealed capacity building, resources for palliative care services, and the existing social structure of the community being the main challenges that need to be overcome for better penetration of CBPC services into society. Demand generation through sensitization and administration of services based on the need and regular follow-up remains the key strategies for the sustainability of the program.

Conclusion

The CBPC program like 'Sanjeevan' adopted in the rural area of Puducherry can be cited as an example and can be replicated in other rural settings with similar sociocultural characteristics to support people living with end-stage diseases.

'The palliative care ambulance': A qualitative study of patient and caregiver perspectives of an ambulance service

BACKGROUND

The need for home-based palliative care is accelerating internationally. At the same time, health systems face increased complexity, funding constraints and global shortages in the healthcare workforce. As such, ambulance services are increasingly tasked with providing palliative care. Where paramedics with additional training in palliative care have been integrated into models of care, evaluations have been largely positive. Studies of patient and family carer experiences of paramedic involvement, however, are limited.

AIM

To explore patient and family caregiver experiences of paramedics' contribution to palliative care at home.

DESIGN

Qualitative interview study. We analysed data within a social constructionist epistemology using reflexive thematic analysis.

SETTING/PARTICIPANTS

Participants receiving specialist palliative care in the community of a metropolitan city of Australia who requested an ambulance between January and August 2018, inclusive.

RESULTS

Participants considered paramedics with expertise and experience in palliative care as an extension of the specialist community palliative care team and held them in high regard. Participants highlighted the importance of: critical palliative care at home and a timely, responsive approach; person-centred paramedics; as well as safety and security.

CONCLUSION

Patients and carers feel safe and secure when they know that highly responsive skilled professional support is available when an unexpected problem or sudden change arises, especially out-of-hours, and that support is delivered in an empathic and person-centred manner.

Epilogue: Reflections from Stakeholders of a Facilitated Community Partnership Developed to Provide Palliative Care to a Vulnerable Population in Kerala

Introduction

In mid-March 2020, the Kerala government implemented additional preventive measures to the steps already taken to reduce the transmission of COVID-19. Strategies were taken by a non-governmental palliative care organisation (Pallium India) with Coastal Students Cultural Forum - a coastal area-based collective of young educated people in the coastal region to address the medical needs of people living in this community. The facilitated partnership lasted 6 months (July-December 2020) and addressed the palliative care needs of the community in the selected coastal regions during the first wave of the pandemic. Volunteers sensitised by the NGO identified more than 209 patients. The current article highlights the reflective narratives of key players in this facilitated community partnership.

Materials and Method

The current article is dedicated to highlighting the reflective narratives of key players in this facilitate community partnership to the readers of this journal. The palliative care team's overall experience was collected from selected key participants to understand the program's impact, identify areas of improvement, and discuss possible solutions if there were any challenges. The contents below are their statements on the experience of the entire program.

Conclusion

Palliative care delivery programmes must be configured to respond to local needs and customs, be community-based and integrated with local health and social care and have accessible referral pathways between and across services. They must also be responsive to changing individual and population needs and shifts in local and national health structures.

Experiences of Volunteers and Patient Satisfaction in Home Based Palliative Care, Puducherry, South India-A Descriptive Qualitative Study

CONTEXT

Increasing burden of non-communicable diseases and ageing population has parallely increased the need for Palliative care. Unavailable, inaccessible, and inadequate palliative care services in our setting increased the need for volunteers. In Puducherry, palliative care programme was implemented through trained volunteers in 2015.

AIMS

To explore the experiences of volunteers who provide palliative care and also to get feedback on volunteering from the patients who received care.

SETTINGS AND DESIGN

A descriptive qualitative study was carried out at two Non-Governmental Organizations (NGO) working for palliative care in and around Puducherry.

METHODS AND MATERIAL

Participants were selected purposively to include seven volunteers and eight patients to attain information saturation. The time period of this study was between September and October 2018.

ANALYSIS USED

Manual thematic analysis was done to identify codes, which were grouped to form categories and themes.

RESULTS

Factors that facilitated participants to take up the role of volunteers were witnessing the death of family members with unmet palliative care when required and experiences in organizations working for elderly and disabled children. Improvement in patients' condition and patient satisfaction motivated them to continue, despite lack of resources and social support. Their perception was of having become bolder and empathetic by working as palliative care volunteers. Patients reported satisfaction with the provision of drugs and other materialistic support like clothes and sweets during festivals; however, their basic and financial needs remained unmet.

CONCLUSION

The palliative care programme or the National programme for elderly should focus on components that would improve the quality of palliative care by reducing patients' dissatisfaction. Support in terms of provision of drugs, financial help and nutrition is necessary to improve both the patients' and volunteers' satisfaction in palliative care services.

Patient, Caregiver, and Taxpayer Knowledge of Palliative Care and Views on a Model of Community-Based Palliative Care

CONTEXT

Palliative care (PC) model delivered by two large hospices and PC providers.

OBJECTIVES

To understand study participants' knowledge of PC and acceptability of a new community-based PC model.

METHODS

Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach.

RESULTS

Across 10 interviews and four focus groups (n = 4-10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services.

CONCLUSION

Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC.

Pain-related distress among patients referred to a community-based palliative care program

OBJECTIVE

Numerous studies have characterized the pain reported by patients with advanced illness in terms of descriptors such as severity, but few have measured pain-related distress. Distress may be important in the clinical approach to pain. To evaluate pain-related distress among adult patients with advanced illness and pain following enrollment in an urban, specialist-level, community-based palliative care program.

METHOD

In a retrospective cross-sectional analysis, data were extracted from the electronic health records of all patients who were able to complete the pain item from the Condensed Memorial Symptom Assessment Scale at the start of care. Bivariate and multivariate analyses evaluated the associations between distress and both sociodemographics and disease-related information.

RESULTS

The 506 patients completing the pain item had a mean (SD) age of 70.7 years (13.8); 64.2% were women, 32.1% were Hispanic, 32.6% were white, and 27.7% were black. Of the 503 patients who indicated some level of distress on a 0-4 scale, 221 (43.7%) had high distress, defined as a score ≥3 ("quite a bit" or "very much"). Cancer diagnosis and poor performance status (unable to care for self) were predictors of high pain-related distress (both p < 0.05).Significance of resultsAmong patients with advanced illness who reported pain at the start of care by a specialist palliative care program, high pain-related distress was common, particularly among those with cancer or poor physical function. Further studies are needed to explore the extent to which pain-related distress should inform the assessment and management of pain.

Symptom Distress Among Diverse Patients Referred for Community-Based Palliative Care: Sociodemographic and Medical Correlates

CONTEXT

Community-based palliative care programs are appearing in the U.S. Many of these programs, particularly those in large cities, serve highly diverse populations. Information about the sources of variation in the conditions that drive illness burden, like symptom distress, may be useful in program planning.

OBJECTIVES

To characterize variation in symptom distress among highly diverse patients referred for palliative care in an urban setting.

METHODS

This is a retrospective cross-sectional survey of data obtained from patients at the time of enrollment in a community-based palliative care program. Symptom distress was measured using the Condensed Memorial Symptom Assessment Scale. Severe distress was defined as reporting either "quite a bit"/"very much" or "frequently"/"almost constantly" for one or more symptoms. Multivariate analysis evaluated the associations between symptom distress and sources of patient variability.

RESULTS

Patients (n = 1532) were aged 72.2 years on average; 60.0% were women, 56.4% were African-American or Hispanic, and 30.8% were non-English speaking. Most had cancer or congestive heart failure (68.6%); 90.2% had a Karnofsky Performance Status score of 40-70. The most prevalent symptoms were fatigue (71.8%), pain (47.3%), and sadness (41.6%); the most distressing symptoms were fatigue (58.5%), worrying (54.8%), and weight loss (52.1%). In multivariate analyses, Caucasian race, non-Asian language, low Karnofsky Performance Status scores, and cancer diagnosis predicted severe symptom distress.

CONCLUSION

In a diverse urban population receiving community-based palliative care, symptoms were highly prevalent and distressing, and both sociodemographic and medical factors predicted severe distress. Program planning should consider the needs of subpopulations at risk for high symptom burden.

Evaluation of Community-based Palliative Care Services: Perspectives from Various Stakeholders

Background

As a part of Memorandum of Understanding with Tamil Nadu Institute of Palliative Medicine, community-based palliative care services have been initiated 2 years back in our urban field practice areas.

Aim

The aim of this study was to evaluate the home care service, a major component of our community-based palliative care, with a view to identify the unmet needs of the services rendered for decision-making about the program.

Materials and Methods

It was a descriptive qualitative design carried out by the authors trained in qualitative research methods. In-depth interviews were done among four patients, seven caregivers, two social workers, six nursing staffs, and six medical interns for a minimum of 20 min. Interviews were audiorecorded, transcribed verbatim, and content analysis was done manually. Ethical principles were adhered throughout the study.

Results

Descriptive coding of the text information was done; later, similar codes were merged together to form the categories. Five categories under the theme of strengths and five codes under the theme of challenges of the home care services emerged out. Categories under strengths were physical management, psychological care, social support, efficient teamwork, and acceptance by the community. Codes for felt challenges were interdisciplinary collaboration, volunteer involvement, training enhancement, widening the services, and enhancing the community support.

Conclusions

This review revealed the concerns of various stakeholders. There is a need for more interprofessional collaborations, where team members understand each other's roles for effective teamwork, as evident from the framework analysis.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

CONTEXT

Community-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models.

OBJECTIVES

To evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles.

METHODS

A retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010-2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization.

RESULTS

The mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40-70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time.

CONCLUSION

The population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.