Della Roberts

Conceptual foundations of a palliative approach: a knowledge synthesis

BackgroundMuch of what we understand about the design of healthcare systems to support care of the dying comes from our experiences with providing palliative care for dying cancer patients. It is increasingly recognized that in addition to cancer, high quality end of life care should be an integral part of care that is provided for those with other advancing chronic life-limiting conditions. A “palliative approach” has been articulated as one way of conceptualizing this care. However, there is a lack of conceptual clarity regarding the essential characteristics of a palliative approach to care. The goal of this research was to delineate the key characteristics of a palliative approach found in the empiric literature in order to establish conceptual clarity.MethodsWe conducted a knowledge synthesis of empirical peer-reviewed literature. Search terms pertaining to “palliative care” and “chronic life-limiting conditions” were identified. A comprehensive database search of 11 research databases for the intersection of these terms yielded 190,204 documents. A subsequent computer-assisted approach using statistical predictive classification methods was used to identify relevant documents, resulting in a final yield of 91 studies. Narrative synthesis methods and thematic analysis were used to then identify and conceptualize key characteristics of a palliative approach.ResultsThe following three overarching themes were conceptualized to delineate a palliative approach: (1) upstream orientation towards the needs of people who have life-limiting conditions and their families, (2) adaptation of palliative care knowledge and expertise, (3) operationalization of a palliative approach through integration into systems and models of care that do not specialize in palliative care.ConclusionOur findings provide much needed conceptual clarity regarding a palliative approach. Such clarity is of fundamental importance for the development of healthcare systems that facilitate the integration of a palliative approach in the care of people who have chronic life-limiting conditions.

Home care nurses’ decisions about the need for and amount of service at the end of life

AIMS We explore home care nurse decision-making about the need for and amount of service by clients and families at the end of life. We identify factors nurses refer to when describing these decisions, situated within contextual features of nursing practice. BACKGROUND Home care nurses are often responsible for decisions which have an impact on the access of clients and families to services at the end of life. Understanding how these decisions, are made, factors that are considered, and contextual influences is critical for improving access and enhancing care. METHODS Qualitative data were collected between 2006 and 2008 from two samples of home care nurses: the first group (n = 29) recorded narrative descriptions of decisions made during visits to families. The second group (n = 27) completed in-person interviews focusing on access to care and their interactions with clients and families. Data were analysed with thematic coding and constant comparison. FINDINGS Participants described assessing client and family needs and capacity. These assessments, at times integrated with considerations about relationships with clients and families, inform predictive judgements about future visits; these judgments are integrated with workload and home health resource considerations. In describing decisions, participants referred to concepts such as expertise, practice ideals and approaches to care. CONCLUSION Findings highlight the role of considerations of family caregiver capacity, the influence of relationships and the importance of the context of practice, as part of a complete understanding of the complexity of access to care at the end of life.

Articulating the Role of Relationships in Access to Home Care Nursing at the End of Life

In this article, we draw on data collected from two samples of home care nurses to examine how relationships between nurses and family caregivers intersected with access to palliative home care nursing services. Participants referred to relationships as important for their practical benefits and for access to care: good relationships enhanced the nurse’s ability to assess clients and families and fostered the family’s trust in the nurse’s care. Although emphasizing the need to build and maintain relationships (often requiring time), participants simultaneously referred to beliefs about the need to control the personal emotions invoked in relationships so as to ensure appropriate access for clients and families. Future research should further explore how the organizational and resource context, and the culture of palliative care, shape nurses’ beliefs about relationships in their practice, the nature and types of relationships that can develop, and both client and family caregivers’ access to care.

Unravelling the Tensions Between Chronic Disease Management and End-of-Life Planning.

An increasing appreciation for the burden that chronic conditions represent for people and for societies has triggered an evolving body of popular and professional conceptualizations of the nature of the chronic disease challenge. In this discussion article, we trace the trajectory of thinking about chronic illness care, surfacing underlying assumptions and drivers that have shaped current dominant models of service delivery. We note significant gaps in these conceptualizations, especially with respect to the reality that many chronic conditions are life limiting. Contrasting chronic disease theorizing with the conversations that have arisen around end-of-life care for other kinds of health conditions, we argue for a shift in our thinking to accommodate the implications of life limitation in our service delivery planning. We see significant leadership potential in optimizing the role nurses can play across the chronic disease trajectory by integrating the healthy optimism of self-care management with the profound compassion of a person-centered palliative approach.

Translational Scholarship and a Palliative Approach: Enlisting the Knowledge-As-Action Framework.

Based on a retheorized epistemology for knowledge translation (KT) that problematizes the “know-do gap” and conceptualizes the knower, knowledge, and action as inseparable, this paper describes the application of the Knowledge-As-Action Framework. When applied as a heuristic device to support an inquiry process, the framework with the metaphor of a kite facilitates a responsiveness to the complexities that characterize KT. Examples from a KT demonstration project on the integration of a palliative approach at 3 clinical sites illustrate the interrelatedness of 6 dimensions—the local context, processes, people, knowledge, fluctuating realities, and values.

Review: walking aids, chest-wall vibration, and neuroelectrical muscle stimulation relieve breathlessness in COPD.

C Bausewein Dr C Bausewein, King’s College London, London, UK; claudia.bausewein@kcl.ac.uk In advanced disease, do non-pharmacological and non-invasive interventions relieve breathlessness? Studies selected evaluated non-pharmacological or non-invasive interventions for breathlessness in patients with dyspnoea because of advanced lung cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure, or motor neurone disease. Outcomes included subjective measures of breathlessness. Medline; EMBASE/Excerpta Medica; CINAHL; Cochrane Central Register of Controlled Trials; Cochrane Pain, Palliative, and Supportive Care Trials Register; Cochrane Database of Systematic Reviews; and 5 other databases (all to Jun 2007); websites; and reference lists were searched. Authors were contacted. 45 randomised controlled …

Embedding a Palliative Approach in Nursing Care Delivery: An Integrated Knowledge Synthesis

A palliative approach involves adapting and integrating principles and values from palliative care into the care of persons who have life-limiting conditions throughout their illness trajectories. The aim of this research was to determine what approaches to nursing care delivery support the integration of a palliative approach in hospital, residential, and home care settings. The findings substantiate the importance of embedding the values and tenets of a palliative approach into nursing care delivery, the roles that nurses have in working with interdisciplinary teams to integrate a palliative approach, and the need for practice supports to facilitate that embedding and integration.

Applying research into practice: a guide to determine the next palliative home care nurse visit.

Beyond their own family caregivers, home healthcare nurses play a pivotal role in caring for those dying at home. However, deciding the timing of the next visit for these patients and their families is not straightforward. The Palliative Care: Determining Next Home Care Nurse Visit decision guide supports clinicians in their decision-making process of planning visits to most effectively meet the needs and goals of patients and families during the final months of life.

Home supported discharge was as effective and safe as standard hospital admission in patients with chronic obstructive pulmonary disease

(2000) Thorax 55, 907. Skwarska E, Cohen G, Skwarski KM, et al. . Randomised controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. . Nov; . : . –12 . [OpenUrl][1][Abstract/FREE Full Text][2] 
 QUESTION: Is immediate or next day home supported discharge as effective and safe as standard hospital admission in patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD)? Randomised {allocation concealed}*, unblinded, controlled trial with 8 weeks of follow up. A hospital in Edinburgh, UK. 184 patients (mean age 69 y, 53% women) who presented to hospital on a weekday with an exacerbation of COPD. Exclusion criteria were an impaired level of consciousness, acute confusion, acute changes on radiography, an arterial pH <7.35, or a serious medical or social reason for admission. Follow up was 93%. 122 patients were allocated to home support and were discharged immediately or the next day with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators, and, if necessary, home oxygen). These patients had a home visit by a respiratory nurse the day after discharge and every 2–3 days thereafter until recovery, at which time they were discharged from follow up. Nurses reviewed patient progress weekly with the consultant. Specialist advice was available daily and changes in prescription could be obtained in consultation with the patients general practitioner (GP). 62 patients were allocated to hospital admission with standard care in … [1]: {openurl}?query=rft.jtitle%253DThorax%26rft.stitle%253DThorax%26rft.issn%253D0040-6376%26rft.aulast%253DSkwarska%26rft.auinit1%253DE%26rft.volume%253D55%26rft.issue%253D11%26rft.spage%253D907%26rft.epage%253D912%26rft.atitle%253DRandomised%2Bcontrolled%2Btrial%2Bof%2Bsupported%2Bdischarge%2Bin%2Bpatients%2Bwith%2Bexacerbations%2Bof%2Bchronic%2Bobstructive%2Bpulmonary%2Bdisease%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fthorax.55.11.907%26rft_id%253Dinfo%253Apmid%252F11050258%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=thoraxjnl&resid=55/11/907&atom=%2Febnurs%2F4%2F3%2F89.atom

Nurse supported early discharge had a readmission rate similar to conventional hospital care in patients with exacerbations of chronic obstructive pulmonary disease

(2000) Thorax 55, 902. Cotton MM, Bucknall CE, Dagg KD, et al. . Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. . Nov; . : . –6 . [OpenUrl][1][Abstract/FREE Full Text][2] 
 QUESTION: How does early discharge with home respiratory nurse support compare with conventional hospital management for subsequent need for readmission in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD)? Randomised (allocation concealed), unblinded, controlled trial with 60 days of follow up. A large university hospital in Glasgow, UK. 81 patients (mean age 67 y, 57% women) who were admitted on an emergency basis with an acute exacerbation of COPD. Exclusion criteria were other medical conditions that required inpatient investigation or management, acidotic respiratory failure, non-resident status in Glasgow, homelessness, or lack of telephone access. 93% of patients received their allocated intervention, but all patients were included in the intention to treat analysis. 41 patients were allocated to early discharge, 36 of whom were sent home the next working day after recruitment. These patients had home visits by specialist respiratory nurses on the first morning after discharge and thereafter at intervals determined by the nurse. Home treatment was based on the practice developed by the Acute Respiratory Assessment Service. The nurse assessed progress and could adjust treatment after discussion with respiratory medical staff. The nurse did not prescribe, but could advise patients on the use of “as required” medication. 40 patients were … [1]: {openurl}?query=rft.jtitle%253DThorax%26rft.stitle%253DThorax%26rft.issn%253D0040-6376%26rft.aulast%253DCotton%26rft.auinit1%253DM%2BM%26rft.volume%253D55%26rft.issue%253D11%26rft.spage%253D902%26rft.epage%253D906%26rft.atitle%253DEarly%2Bdischarge%2Bfor%2Bpatients%2Bwith%2Bexacerbations%2Bof%2Bchronic%2Bobstructive%2Bpulmonary%2Bdisease%253A%2Ba%2Brandomised%2Bcontrolled%2Btrial%26rft_id%253Dinfo%253Adoi%252F10.1136%252Fthorax.55.11.902%26rft_id%253Dinfo%253Apmid%252F11050257%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=thoraxjnl&resid=55/11/902&atom=%2Febnurs%2F4%2F3%2F88.atom