Specialist Palliative Care Inpatient Unit Research Articles

The effect of implementing the COMFORT communication model on communication skills of nursing students.

Effective communication as a key component of palliative care requires sufficient knowledge and experience to make nursing interventions successful. This quasi-experimental study was conducted to determine the effectiveness of the COMFORT communication model as an intervention to improve student nurses' communication skills while they are under clinical training in specialist palliative care inpatient units. The population sample included 86 student nurses who were randomly assigned into two groups of 40. The intervention group received training on communication skills using the COMFORT communication model. Nine lectures were delivered online or offline; the lectures lasted between 25 to 60 minutes. The control group received the conventional educational programme about communication with patients and families, according to the curriculum of the bachelor's degree in nursing. Data were collected using the Communication Skills Questionnaire and Communication Skills Attitude Scale and analysed using IBM® SPSS® Statistics 22.0. The findings showed that, after the implementation of COMFORT communication model, there was a statistically significant difference in communication skills between the intervention group (122.95±9.36) and the control group (110.1±8.92). There was also a significant difference in attitudes toward communication skills between the intervention group (90.25±8.86) and the control group (90.85±9.15) (P=0.0001). The findings of the study revealed that the COMFORT Communication model created significant statistical differences in the student's attitude, knowledge and communication skills. Novice nurses sometimes struggle with the level of communication skills needed when caring for patients with an end-stage illness. The implementation of the COMFORT communication model significantly improved communication skills and attitudes toward communication. Due to the need to establish effective communication as the core of nursing practice, the implementation of this training programme is recommended for students and qualified nurses, particularly when providing palliative care.

Family members' experiences of psychosocial support in palliative care inpatient units: A descriptive qualitative study.

The support for family members (FMs) during a patient's palliative hospital care has been rarely studied, creating a gap in how FMs can be better supported. Psychosocial support answers widely to FMs' needs. Therefore, this study aims to describe FMs' experiences of psychosocial support in specialist palliative care inpatient units from the perspective of the FMs themselves. A qualitative descriptive study with individual semi-structured interviews and inductive content analysis was conducted. Data were collected in four specialist palliative care inpatient units in two large hospital districts in Finland. The 32-item checklist Consolidated Criteria for Reporting Qualitative Studies was used to ensure detailed reporting. A total of 19 FMs of cancer patients receiving palliative care participated in the study. Their experiences of psychosocial support focused on Support FMs hoped for, Support practices in the care unit, and Informational support for FMs. According to FMs' experiences, support focusing particularly on the FMs, safe quality patient care, proper access to information regarding the patient's care and condition, and genuine encounters with HCPs were the aspects that seemed to be the most important to the FMs. Systematic provision of support and information should be a routine model in palliative care. Additionally, a care environment that promotes FMs' presence, participation, and family-centred care is essential in FMs' support and should be considered when developing family involvement in palliative care. Furthermore, the importance of FMs receiving sufficient information, and FMs' dependence on HCPs to share the needed information, should be acknowledged. Hence, more attention should be paid to successful information sharing between the HCPs and FMs in palliative hospital care.

Patients Receiving Palliative Care and Their Experiences of Encounters With Healthcare Professionals.

The study aimed to explore experiences of encounters with health care professionals among patients receiving palliative cancer care in specialist palliative care inpatient units. A qualitative explorative study design was conducted in a specialist palliative care inpatient setting. Data collection was implemented using semi-structured individual interviews (20 palliative care cancer patients) and analysed with inductive content analysis. Palliative care patients experienced both meaningful and disrespectful encounters with healthcare professionals. The meaningful encounters encompassed authentic and supportive experiences, while the disrespectful encounters included indifferent and inadequate experiences. Caring for a patient receiving palliative care requires care beyond tending to a patient's physical needs. Patients should be encountered holistically and as equal human beings without highlighting their roles as patients. The healthcare professionals and the organisations should also acknowledge the importance of time and effort spent for encounters and conversations with the patients instead of concentrating resources mainly on physical care.

Palliation in a pandemic: the human cost of achieving the greater good

The onset of the COVID-19 pandemic in early 2020 created major challenges for specialist palliative care services. Significant ethical challenges have arisen in practising a holistic approach to patient and family care, while observing local and national health care policy in the face of a global pandemic. This report highlights the challenges that arose for a patient, family members and staff consequent on COVID-related visiting restrictions. An integrated specialist palliative care inpatient unit and elderly care facility in Ireland. A 50-year-old married mother of three teenagers and one 12-year-old child with advanced amyotrophic lateral sclerosis is described. The patient could not speak or move her limbs. She communicated using an eye gaze device. She had previously declined enteral feeding, and noninvasive ventilatory support was not tolerated. Her husband was particularly attentive and remarkably intuitive in identifying her unspoken needs. At the start of the pandemic, visiting was severely curtailed in line with national policies. The change in visiting policies caused enormous distress to the patient, her family and to the staff members. IT devices were of limited benefit. The current pandemic has had a significant impact on families and health care professionals in which balancing individual need and traditional freedoms against the wider societal need are necessary in limiting the spread of COVID-19.

Patients Receiving Palliative Care and Their Families' Experiences of Participating in a "Patient-Centered Family Meeting": A Qualitative Substudy of the Valuing Opinions, Individual Communication, and Experience Feasibility Trial.

Background: Family meetings are used in palliative care to facilitate discussion between palliative patients, their families, and the clinical team. However, few studies have undertaken qualitative assessment of the impact of family meetings on patients and their families.Objectives: To explore inpatients receiving palliative care and their families' experiences of participation in a patient-centered family meeting (“Meeting”), where the patient sets the Meeting agenda.Design: This qualitative study used the constant comparative method for thematic content analysis of the data.Setting/Participants: The setting was a specialist palliative care (SPC) inpatient unit in Australia. Nine palliative care inpatients and nine family members were interviewed.Measurements: Semistructured interviews were used evaluate the patients' and their families' experiences and perceptions of the Meeting.Results: Three overarching themes described the experiences of participating in a patient-focused family meeting, namely that the Meeting: (1) provides a forum for inpatients receiving SPC to speak openly about their end-of-life concerns, clarify issues, and is of comfort to patients; (2) provides the family members with a voice, and an opportunity to discuss their concerns and have their needs addressed; and (3) helps to ensure that everyone is “on the same page” and patient care plans can be discussed.Conclusions: These Meetings are a potentially effective means of supporting certain palliative care patients and their families to articulate, confront, and address end-of-life issues in the presence of the interdisciplinary team. It is important to undertake further research to further examine the evidence for this Meeting model and to identify the patients and families who would most benefit from this type of Meeting.

Adaptation of the Australian Palliative Care Phase concept to the German palliative care context: a mixed-methods approach using cognitive interviews and cross-sectional data

BackgroundPalliative care phases (stable, unstable, deteriorating, terminal and bereavement) are routinely used in Australia and the UK to describe the clinical situation of patients and their families and to evaluate the associated care plan. In addition, it serves as a benchmark developed by the Australian Palliative Care Outcome Collaboration (PCOC) and is used nationwide for comparisons between services. In Germany, the concept is not used consistently due to various translations. Furthermore, there is no nationwide systematic approach to routinely assess clinical outcomes in palliative care.The study aims to develop a German version of the palliative care phase definitions by adapting them culturally, and to examine the inter-rater reliability of the adjusted definitions with healthcare professionals.MethodsMixed-methods approach: Cognitive interview study using ‘think aloud’ and verbal probing techniques and a consecutive multi-center cross-sectional study with two clinicians independently assigning the phase definitions. Interviewees/participants were selected through convenience and purposive sampling in specialist palliative care inpatient units, advisory and community services and in three specialist palliative care units with doctors, nursing staff and allied health professionals.ResultsFifteen interviews were conducted. Identified difficulties were: Some translated terms were 1) not self-explanatory (e.g. ‘family/carer’ or ‘care plan’) and (2) too limited to the medical dimension neglecting the holistic approach of palliative care. (3) Problems of comprehension regarding the concept in general occurred, e.g. in differentiating between the ‘unstable’ and ‘deteriorating’ phase. Inter-rater reliability was moderate (kappa = 0.44; 95% CI = 0.39–0.52). The assignment of the phase ‘deteriorating’ has caused the most difficulties.ConclusionOverall, the adapted palliative care phases are suitable to use in the German specialist palliative care setting. However, the concept of the phases is not self-explanatory. To implement it nationwide for outcome measurement/benchmarking, it requires further education, on-the-job training and experience as well as the involvement of healthcare professionals in implementation process. For the use of international concepts in different healthcare systems, a deeper discussion and cultural adaptation is necessary besides the formal translation.

Exploring Awareness of Spirituality in Physicians Working in an Inpatient Specialist Palliative Care Unit

Exploring Awareness of Spirituality in Physicians Working in an Inpatient Specialist Palliative Care Unit

Family Meetings in Inpatient Specialist Palliative Care: A Mechanism to Convey Empathy

ContextFamily meetings are increasingly used in palliative care, yet have little empirical evidence of their impact in inpatient settings. ObjectivesTo examine whether relatives report more empathy after a family meeting in a specialist palliative care inpatient ward. MethodsPre/post self-complete questionnaires measuring relational empathy and information needs were administered. Qualitative interviews were also conducted. Data were collected during nine months from one inpatient specialist palliative care unit. Participants from 52 family meetings completed pre/post questionnaires, and 13 relatives participated in an interview that was analyzed thematically. ResultsFamilies reported more empathy from staff after a family meeting (Wilcoxon test: n = 47; P > 0.001; Z score −4.17). Some families with relatives who do not speak with each other reported that meeting facilitators were unable to manage the pre-existing dynamics. ConclusionFamily meetings improve reported empathy. It would be beneficial to have more specific preparation and planning by the clinical team for meetings with people who have a history of familial conflict, and those where the staff's agenda is around discharge planning. Published guidelines could be adapted to better support staff to run meetings where there are complex family dynamics. Adoption of family meetings in outpatient settings has the potential to improve perceptions of empathy with a larger patient group.

Dying at home the Midhurst way

Ensuring high quality of care for dying patients and their families is a challenge for both primary and specialist palliative care services throughout the UK. A model of a consultant-led palliative care community team was set up following the closure of a specialist palliative care inpatient unit in Midhurst, with the aim of providing that same level of care to patients in their own homes, care homes and community hospitals. It works closely with primary care to enhance community services and with secondary care to enable rapid discharge from hospital to the community. Anticipatory prescribing, advanced care planning and education of social care and nursing home staff are also key aspects of the service. The Macmillan Midhurst Service costs an average of less than £3,000 per patient and enables 85% of referred patients to die in their preferred place. Evaluations of the service have highlighted benefits to patients and families as well as cost reductions to the NHS of around 20% when patients are referred early.

An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland

An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland

A quality improvement approach to cognitive assessment on hospice admission: could we use the 4AT or Short CAM?

Background Prevalence studies show that 13%–42% of patients admitted to specialist palliative care inpatient units have delirium. Symptoms of delirium are often subtle and easily missed, or misdiagnosed as fatigue...

The Introduction of Patient’s Own Drug Scheme in a Specialist Palliative Care Inpatient Unit

Patient’s own drug scheme (PODS) involves the use of patient’s own medicines that they have obtained in the community setting and bring to the hospital. The purpose of this study is to evaluate the effectiveness of PODS implementation in an Irish specialist palliative care inpatient unit. Administration time for drug rounds (PODS vs drug trolley); experience of nurses, doctors, and pharmacists using PODS; and the cost effectiveness of PODS were evaluated. Time spent on PODS-related tasks was documented for 1 month; focus groups were undertaken with nursing staff (n = 9), pharmacy staff (n = 3), and doctors (n = 5) to determine their experience of the PODS; and a cost/savings analysis was conducted. Although a minimal difference in the number of minutes to administer drugs per patient was noted, using PODS enabled simultaneous administration of drugs that potentially reduced drug round time by up to 75%. Nursing, doctors, and pharmacy staff demonstrated a good understanding of PODS and identified many benefits (and few disadvantages) for the organization, patient, and team. The PODS resulted in a median pharmacy drug cost saving of approximately €77.50 ($86.79) per patient. The introduction of PODS was successful and is being implemented across all units of the specialist palliative care inpatient service.

The Association of Hydration Status with Physical Signs, Symptoms and Survival in Advanced Cancer-The Use of Bioelectrical Impedance Vector Analysis (BIVA) Technology to Evaluate Fluid Volume in Palliative Care: An Observational Study.

BackgroundHydration in advanced cancer is a controversial area; however, current hydration assessments methods are poorly developed. Bioelectrical impedance vector analysis (BIVA) is an accurate hydration tool; however its application in advanced cancer has not been explored. This study used BIVA to evaluate hydration status in advanced cancer to examine the association of fluid status with symptoms, physical signs, renal biochemical measures and survival.Materials and methodsAn observational study of 90 adults with advanced cancer receiving care in a UK specialist palliative care inpatient unit was conducted. Hydration status was assessed using BIVA in addition to assessments of symptoms, physical signs, performance status, renal biochemical measures, oral fluid intake and medications. The association of clinical variables with hydration was evaluated using regression analysis. A survival analysis was conducted to examine the influence of hydration status and renal failure.ResultsThe hydration status of participants was normal in 43 (47.8%), 'more hydrated' in 37 (41.1%) and 'less hydrated' in 10 (11.1%). Lower hydration was associated with increased symptom intensity (Beta = -0.29, p = 0.04) and higher scores for physical signs associated with dehydration (Beta = 10.94, p = 0.02). Higher hydration was associated with oedema (Beta = 2.55, p<0.001). Median survival was statistically significantly shorter in 'less hydrated' patients (44 vs. 68 days; p = 0.049) and in pre-renal failure (44 vs. 100 days; p = 0.003).ConclusionsIn advanced cancer, hydration status was associated with clinical signs and symptoms. Hydration status and pre-renal failure were independent predictors of survival. Further studies can establish the utility of BIVA as a standardised hydration assessment tool and explore its potential research application, in order to inform the clinical management of fluid balance in patients with advanced cancer.

Screening for delirium in specialist palliative care inpatient units: perceptions and outcomes.

The UK National Institute for Health and Care Excellence (NICE) indicate that palliative care patients are at high risk of delirium and should be screened for it using the short confusion assessment method (short CAM). This study aimed to assess the perceptions of the short CAM for delirium screening amongst health-care workers in specialist palliative care inpatient units (SPCUs) and to investigate its use as a screening instrument. Patients in 5 SPCUs in the North East of England were screened for delirium using the short CAM and a staff survey assessed the acceptability of the short-CAM in this setting. Of the 63 staff surveyed, 79.4% felt screening for delirium was important and 59.3% found the short CAM 'not at all' burdensome to complete. However, only 40.7% felt that the short-CAM often accurately reflected patients' conditions and none felt it always accurately reflected patients' condition. Of 298 patients screened, 20% screened positive on the short CAM. Malignant and intra-cerebral diseases were significant independent predictors of a positive screen. Hospice length of stay and in-hospice mortality were higher in those with a positive result (66.7%) than in those without (38.2%). Health professionals deem delirium screening to be important in SPCUs, but may not support routine use of the short CAM. This could reflect a limited perceived impact on care and lack of confidence in this tool to reflect a complex patient group.

Implementing a patient-centred outcome measure in daily routine in a specialist palliative care inpatient hospital unit: An observational study

Background: Gathering clinical evidence data on patients’ palliative care needs is paramount to identify changes in outcomes over time and maintaining on-going quality improvement. Implementation of patient-centred outcome measures has been widely recommended. The routine use of these instruments in daily practice is challenging and not widespread. Aim: To implement a patient-centred outcome measure in daily practice and fulfil one quality indicator: improve pain during the 72 h after admission, in at least 75% of patients. Design: An observational prospective study. The Palliative care Outcome Scale was used at admission (T0), third day (T1) and weekly. Setting/participants: Hospital palliative care unit with 17 individual rooms. All patients admitted to the unit were included in the study. Results: Preliminary results (N = 84) revealed inconsistent and missing data (14%). Symptoms were sub-optimally controlled by T1. Processes changed, and only a team member could apply Palliative care Outcome Scale. Doctors were encouraged to grasp the meaning of Palliative care Outcome Scale results for each patient. The post-pilot included 317 patients. No missing data occurred. There was an improvement in most items between T0 and T1: ‘pain’ and ‘other symptoms’ presented statistical significant differences (p < 0.05). Conclusion: Implementing a patient-centred outcome measure in a hospital palliative care service is feasible and improves quality of care. Controlling high pain at T0 improved (>80%) by T1. Results became more consistent and symptom control was improved overall. Patients are evaluated based on holistic domains by an interdisciplinary team and we have added a much needed measure to help guide improvement of the quality of care provided.

The Impact of a Novel Tool for Comprehensive Assessment of Palliative Care (MPCAT) on Assessment Outcome at 6- and 12-Month Follow-Up

ContextAssessment in palliative care settings should be focused, sensitive, specific, and effective to minimize discomfort to vulnerable and often highly morbid patients. This report describes the development of an admission assessment protocol for a Specialist Palliative Care Inpatient Unit and its implementation into clinical practice. ObjectivesThe aim of this study was to develop and investigate the impact of the implementation of a Specialist Palliative Care admission assessment tool on documentation of key patient needs. MethodsThe outcome of a systematic literature review was used to develop an admission assessment protocol (the intervention) in a Specialist Palliative Care Inpatient Unit. Mixed methods were used to facilitate a comprehensive evaluation pre- and post-intervention to test the effectiveness, feasibility, and acceptability of the intervention. ResultsThe documented evidence of pain assessment improved from a baseline rate of 71% to 100% post-intervention. This improvement was maintained 12 months post-introduction of the tool (P < 0.001). The documented evidence of screening for spiritual distress increased from a baseline rate of 23% to 70% at 6 months and to 82% at 12 months (P < 0.001). The number of referrals made in the first 24 hours after assessment increased post-intervention (physiotherapy, P = 0.001; occupational therapy, P = 0.001; social work, P = 0.005; pastoral care, P = 0.005); this was maintained at 12 months. Significantly, more clinicians (88%) agreed that palliative care domains were comprehensively assessed post-intervention in comparison with 59% pre-intervention (P = 0.01). ConclusionIntroducing the Milford Palliative Care Assessment Tool was associated with significant improvement in assessment of multiple important aspects of patient need.

An Exploration of Specialist Palliative Care Nurses’ Experiences of Providing Care to Hospice Inpatients from Minority Ethnic Groups—Implication for Religious and Spiritual Care

The aim of this research study was to gain an understanding of nurses’ experiences of providing care to patients from minority ethnic groups within the specialist palliative care inpatient unit of an Irish hospice. Five nurses working in a hospice inpatient unit with experience in providing care to patients from minority ethnic groups were interviewed using a hermeneutic phenomenological approach. Analysis of the data resulted in the emergence of two distinct constructs, “encountering a landscape of diversity” and “negotiating this landscape”, each one comprising three themes. Findings relating to religion and supporting patients’ religious needs were dominant in four of the six emergent themes—death and dying, acceptance, feeling their way, and being resourceful. The findings presented in this paper highlight the personal and professional challenges facing nurses when providing care in the context of religious diversity. In addition, participants’ descriptions of their endeavours to negotiate the challenges in the context of these differences are identified. By applying these findings in practice, healthcare professionals hold the potential to positively impact the quality-of-life of patients, their families, and their experiences of hospice care in Ireland.

Cancer Cachexia Assessment in a Specialist Palliative Care Inpatient Unit (FR441B)

and disease-specific features, and it may be changing over time. Research Objectives. To evaluate associations of demographic variables (diagnosis, race, religion, language) with end-of-life characteristics (Phase I enrollment, Do-Not-Resuscitate (DNR) status, hospice utilization, location of death), and trends in palliative care services delivered to pediatric hematology, oncology, and stem cell transplant (SCT) patients. Methods. In this single-center retrospective cohort study, inclusion criteria were patients aged 0-35 who died between January 1, 2002 and March 1, 2014 who had been cared for in the pediatric hematology, oncology, and SCT divisions. Univariate and multivariate models were used to evaluate associations. The era of 2002-2014 was divided into quartiles to assess trends over time. Results. Of the 445 included patients, 64% of patients had relapsed, 45% were enrolled in hospice, and 16% had received a palliative care consultation. Patients who had brain or solid tumors enrolled in hospice (p<0.0001) and died at home more frequently than patients with leukemia/lymphoma (p<0.0001). Patients who received Phase I therapy or identified as Christian/Catholic religion enrolled in hospice more frequently (p<0.0001 and p1⁄40.03, respectively). When patient deaths were analyzed over quartiles, the frequency of DNR orders (p1⁄40.02), and palliative care consultation (p1⁄40.04) increased over time. Hospice enrollment, location of death, and Phase I trial enrollment did not significantly change. Conclusion. Despite increases in palliative care consultation and DNR orders over time, utilization remains suboptimal. No increase in hospice enrollment or shift in death location was observed. Implications for Research, Policy, and Practice. These data will help target future initiatives to achieve earlier discussions of goals of care and improved palliative care for all patients.

Locating care at the end of life: burden, vulnerability, and the practical accomplishment of dying.

Home is frequently idealised as the preferred location for end-of-life care, while in-patient hospital care is viewed with suspicion and fear. Yet many people with a terminal illness spend their final days in some form of medicalised institutional setting, such as a specialist palliative care in-patient unit. Drawing on semi-structured interviews with in-patients at a specialist palliative care unit, we focus on their difficulties in finding a better place of care at the end of their life. We found that participants came to conceptualise home though a sense of bodily vulnerabilities and that they frequently understood institutional care to be more about protecting their family from the social, emotional and relational burdens of dying. For a significant number of participants the experience of dying came to be understood through what could be practically accomplished in different locales. The different locales were therefore framed around providing the best care for the patient and their family.

Butterfly Glioma Involving Splenium of Corpus Callosum

61 year old male presented with headache, nausea, vomiting, disorientation and ataxia. MRI brain revealed a heterogenous solitary mass suggestive of glioblastoma multiforme involving the splenium of the corpus callosum and crossing the midline, measuring 5.4 cm in transverse, 3.6 cm in antero-posterior, 3.3 cm in craniocaudal dimensions (Figures 1 and 2). Surrounding peritumoural edema was evident. Glioblastoma multiforme (WHO grade IV) was subsequently confirmed on biopsy and deemed inoperable by the neurosurgical team. The patient’s performance status precluded palliative chemotherapy. He was referred to the specialist palliative care inpatient unit to facilitate the planned ten fractions of palliative whole brain radiotherapy in conjunction with steroid therapy. Unfortunately his condition deteriorated further and he was unable to complete the planned protocol. Glioblastoma multiforme is the most common primary intra-axial malignancy, accounting for 12-15% of all intracranial neoplasms. It generally originates in the cerebral white matter and spreads along the corpus callosum in a “butterfly” pattern to the opposite side. The corpus callosum is divided into rostrum, genu, body, isthmus, and posteriorly, the splenium. The fibres in the splenium connect posterior parietal, medial occipital, and medial temporal cortexes. The splenium is primarily affected in this case and represents the least common are of callosal involvement (10%). Prognosis is poor. The median survival time from the time of diagnosis without any treatment is 3-6 months, but with treatment survival of 1-2 years is common. Increasing age (>60 years of age), abnormal brain function, or significant disabilities carry a worse prognostic risk.