Alan Taniguchi

A Shared Care Model Pilot for Palliative Home Care in A Rural Area: Impact on Symptoms, Distress, and Place of Death

CONTEXT Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs. OBJECTIVES To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death. METHODS An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models. RESULTS Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed. CONCLUSION Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.

A Systematic Review of Postgraduate Palliative Care Curricula

BACKGROUND Palliative care is part of comprehensive family practice; however, many physicians do not feel confident in the biomedical and psychosocial realms. Although improving residency training to address this is necessary, there is little consensus on the best education methods. OBJECTIVE To conduct a systematic review of postgraduate curricula in palliative care to incorporate the most effective components into a family medicine education program. METHODS Studies of palliative care curricula conducted in postgraduate medical training programs that contained an evaluative component and published since 1980 were systematically examined by investigator pairs using standard selection criteria and data collection forms. Discrepancies were resolved by consensus. The outcomes examined were communication skills, knowledge, attitudes, and comfort/confidence level. RESULTS 28 studies were included after reviewing 174 abstracts. Most studies (n = 21) used survey pre-post design with no control group. Outcomes were grouped into communication skills, knowledge and attitudes and confidence. Workshops with simulated patients or role plays improved communication skills. Relatively brief strategies such as short workshops showed objective improvements in focused knowledge areas. Either clinical rotations or multi-faceted interventions were required to produce improvements more broadly in knowledge base. Only a few studies examined the sustainability of outcomes. CONCLUSIONS An effective palliative care curriculum will need to use a multifaceted approach, incorporating a variety of intentional strategies to address the multiple competencies required. There is a need for more rigorous curricular evaluation.

A Method to Enhance Student Teams in Palliative Care: Piloting the McMaster-Ottawa Team Observed Structured Clinical Encounter

BACKGROUND The need for palliative and end-of-life care (PEOLC) education in prelicensure education has been identified. PEOLC requires effective collaborative teamwork. The competencies required for effective collaborative teamwork are only now emerging and methods to evaluate them must be developed. OBJECTIVE The adaptation of the traditional Objective Structured Clinical Examination (OSCE) for assessment of a student team addressing palliative care issues was undertaken. The McMaster-Ottawa Team Observed Structured Clinical Encounter (TOSCE) is intended as a formative evaluation tool for both competencies in interprofessional collaboration for patient-centered practice and PEOLC. METHODS Three stations based on palliative care scenarios were developed. From January 2007 to January 2008, a total of 141 students and 38 observers participated in the evaluation of three stations, with 6-7 students per group and two observers per station. Observers completed checklists for both PEOLC and interprofessional collaborative competencies and, after completing the TOSCEs, students and observers completed questionnaires on their feasibility and acceptability. RESULTS Eighty-nine percent of the students and 44% of the observers were from medicine. Students and observers found the TOSCE to be an acceptable and feasible assessment tool for both sets of competencies. Reliability and validity data show that the items in both the clinical and interprofessional checklists fit well together, and interrater reliability is readily achieved. CONCLUSIONS The new formative evaluation TOSCE tool, adapted from the traditional OSCE, was acceptable and feasible to students and observers.

Team OSCEs: evaluation methodology or educational encounter?

Context and setting In their penultimate year at our university, all medical students participate in a workshop involving bereaved lay caregivers during their palliative medicine course. The aim of this workshop is to provide students with the opportunity to better understand the caregivers’ perspective by hearing their stories directly from them, then reflecting upon these narratives and discussing the wider lessons to be learned from these individual experiences. Why the idea was necessary In medical education, there is a justifiably strong focus on the patient but much less opportunity to study the perspectives of the patient’s primary caregiver. Despite the caregiver’s often significant influence on patient views and care, the focus of most interactions between doctors and caregivers is limited to obtaining, or corroborating, the patient’s history. Increasingly, communication extends to sharing information about the patient’s condition and treatment. Rarely is the caregiver’s welfare considered in its own right. The palliative medicine course is ideal for embedding these learning opportunities because of the close involvement of lay caregivers in the care of dying people and those with advancing disease. Having accompanied a relative through an illness journey, bereaved caregivers carry a wealth of experience and observations which could provide powerful and authentic learning. What was done A 2-hour workshop was designed, building on prior experience of involving lay caregivers in interprofessional education in another setting. Twomonthly workshops are held, halfway through each palliative medicine course. Each workshop is attended by 28 medical students and jointly facilitated by a nurse and a doctor; five recently bereaved caregivers participate each time. The students and caregivers are separately briefed, after which each carer spends 30 minutes with a small group of students, relating his or her story and responding to questions. Although some guide questions are provided, these sessions are unscripted and facilitated only by the students themselves. Then, whilst the carer is debriefed, the students spend 20 minutes discussing the experience before presenting their reflections in whatever format they choose, back in plenary. The facilitators help the students to draw out the themes and discuss learning points. Evaluation of results and impact In the 4 years since we introduced these workshops, feedback from students has been consistently positive, reflected both in the open-ended questionnaires completed at the end of the workshop and in written and verbal feedback at the end of the palliative medicine course. In terms of what they learned about caregivers’ perspectives, students have identified: the need for practical and psychological support and information; varying coping mechanisms; exhaustion caused by constant care; the importance of involving caregivers without over-burdening them with responsibility, and the impact on the caregiver of putting ‘life on hold’. Students found the experience thought-provoking, insightful and ‘very real’, and were appreciative of the caregivers’ willingness to participate in these workshops. Many would have preferred more time with the caregiver. This is currently under consideration. Caregivers were equally positive about the experience and appreciated the direct opportunity to participate in medical education and to influence these future doctors.

Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study

BackgroundResearch evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.MethodsThe study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.ResultsTwo major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.ConclusionsThe perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.

Measuring horizontal integration among health care providers in the community: an examination of a collaborative process within a palliative care network

Abstract In many countries formal or informal palliative care networks (PCNs) have evolved to better integrate community-based services for individuals with a life-limiting illness. We conducted a cross-sectional survey using a customized tool to determine the perceptions of the processes of palliative care delivery reflective of horizontal integration from the perspective of nurses, physicians and allied health professionals working in a PCN, as well as to assess the utility of this tool. The process elements examined were part of a conceptual framework for evaluating integration of a system of care and centred on interprofessional collaboration. We used the Index of Interdisciplinary Collaboration (IIC) as a basis of measurement. The 86 respondents (85% response rate) placed high value on working collaboratively and most reported being part of an interprofessional team. The survey tool showed utility in identifying strengths and gaps in integration across the network and in detecting variability in some factors according to respondent agency affiliation and profession. Specifically, support for interprofessional communication and evaluative activities were viewed as insufficient. Impediments to these aspects of horizontal integration may be reflective of workload constraints, differences in agency operations or an absence of key structural features.

Measuring healthcare integration: Operationalization of a framework for a systems evaluation of palliative care structures, processes, and outcomes

Background: Healthcare integration is a priority in many countries, yet there remains little direction on how to systematically evaluate this construct to inform further development. The examination of community-based palliative care networks provides an ideal opportunity for the advancement of integration measures, in consideration of how fundamental provider cohesion is to effective care at end of life. Aim: This article presents a variable-oriented analysis from a theory-based case study of a palliative care network to help bridge the knowledge gap in integration measurement. Design: Data from a mixed-methods case study were mapped to a conceptual framework for evaluating integrated palliative care and a visual array depicting the extent of key factors in the represented palliative care network was formulated. Setting/participants: The study included data from 21 palliative care network administrators, 86 healthcare professionals, and 111 family caregivers, all from an established palliative care network in Ontario, Canada. Results: The framework used to guide this research proved useful in assessing qualities of integration and functioning in the palliative care network. The resulting visual array of elements illustrates that while this network performed relatively well at the multiple levels considered, room for improvement exists, particularly in terms of interventions that could facilitate the sharing of information. Conclusion: This study, along with the other evaluative examples mentioned, represents important initial attempts at empirically and comprehensively examining network-integrated palliative care and healthcare integration in general.

Assessing family members' satisfaction with information sharing and communication during Hospital care at the end of life

CONTEXT Despite the fact that most deaths occur in hospital, problems remain with how patients and families experience care at the end of life when a death occurs in a hospital. OBJECTIVES (1) assess family member satisfaction with information sharing and communication, and (2) examine how satisfaction with information sharing and communication is associated with patient factors. METHODS Using a cross-sectional survey, data were collected from family members of adult patients who died in an acute care organization. Correlation and factor analysis were conducted, and internal consistency assessed using Cronbachs alpha. Linear regression was performed to determine the relationship among patient variables and satisfaction on the Information Sharing and Communication (ISC) scale. RESULTS There were 529 questionnaires available for analysis. Following correlation analysis and the dropping of redundant and conceptually irrelevant items, seven items remained for factor analysis. One factor was identified, described as information sharing and communication, that explained 76.3% of the variance. The questionnaire demonstrated good content and reliability (Cronbachs alpha 0.96). Overall, family members were satisfied with information sharing and communication (mean total satisfaction score 3.9, SD 1.1). The ISC total score was significantly associated with patient gender, the number of days in hospital before death, and the hospital program where the patient died. CONCLUSIONS The ISC scale demonstrated good content validity and reliability. The ISC scale offers acute care organizations a means to assess the quality of information sharing and communication that transpires in care at the end of life.

The evaluation of a national interprofessional palliative care workshop

Abstract The purpose of this study was to evaluate the impact of a palliative/end-of-life care workshop on students’ perceptions of professional identity, team understanding, and their readiness for interprofessional education (IPE). A before-and-after design was used combining both qualitative and quantitative methods. A survey was completed by 25 undergraduate students from a variety of health care professional schools across Canada, both before and after they attended the five-day workshop. There was a significant increase in students’ readiness for IPE, perceptions of professional identity, and team understanding after they attended the palliative care workshop. Students stated that learning about other professionals’ backgrounds and becoming more sensitive to other team members and their scopes of practice helped change the way they would practice. The findings from this study will contribute to our understanding of student attitudes around IPE and palliative care.

Perspectives of Nurse Practitioner–Physician Collaboration among Nurse Practitioners in Canadian Long-Term Care Homes: A National Survey

Nurse practitioners (NPs) can play an important role in providing primary care to residents in long-term care (LTC) homes. However, relatively little is known about the day-to-day collaboration between NPs and physicians (MDs) in LTC, or factors that may influence this collaboration. Survey data from NPs in Canadian LTC homes were used to explore these issues. Thirty-seven of the 45 (82%) identified LTC NPs across Canada completed the survey. NPs worked with an average of 3.4 MDs, ranging from 1-26 MDs. The most common reasons for collaborating included managing acute and chronic conditions, and updating MDs on resident status changes. Satisfaction with NP-MD collaboration was high, and did not significantly differ among NPs working full versus part time, NPs working in a single versus multiple homes, or NPs with more versus less experience. By understanding the nature of NP-MD collaboration, we can identify ways of supporting and enhancing collaboration between these professionals.