Mieke Vermandere

Defining the palliative care patient: A systematic review

Background: The lack of a clear definition of the palliative care patient hampers the comparison of results across different studies and impedes implementation of research findings in everyday practice. Aim: The aim of this article is to propose minimum characteristics that define a palliative care patient. Design: The design involved a systematic review of medical literature searching randomised controlled trials (RCTs) in palliative care for clear descriptions of their palliative care patients. We systematically describe relevant characteristics of the study populations of 60 eligible RCTs. Data sources: The data sources used were MEDLINE, EMBASE, CINAHL, and PSYCHINFO, including all non-cancer RCTs (1 January 1995–4 March 2010) and an equivalent number of the most recent cancer RCTs (1 January 2003–4 March 2010). Results: Half of the non-cancer studies were excluded because they did not relate to palliative care. We conclude that published RCTs have no clear definitions of their palliative care patients and illustrate the diversity of this patient, the lack of consensus concerning the attributes of illnesses needing palliation and the ambiguous use of the adjective ‘palliative’. Conclusions: We propose elements of the patients’ health status (e.g. a progressive, life-threatening disease with no possibility of obtaining remission or stabilisation, or modifying the course of the illness) and the care delivered to them (e.g. a holistic interdisciplinary approach that focuses on supporting the quality of the end of life) to be included in the definition of a palliative care patient. We also suggest considering the patients’ readiness to accept palliative care and a vision of palliative care shared by the patient and all caregivers involved as potentially important elements in this definition.

Spirituality in palliative home care: a framework for the clinician

PurposeSpiritual care at the end of life remains poorly understood despite its promotion by the World Health Organisation. The purpose of this paper was to develop a consensus-based framework of the main elements of spiritual care in palliative home care.MethodsExpert meeting using the nominal group technique, followed by a two-stage web-based Delphi process, was used. Experts from three stakeholder groups (physicians, professional spiritual care givers and researchers) representing two countries (Belgium and the Netherlands) participated in this study.ResultsFourteen elements of spiritual care were retained: (1) being sensitive to patient’s fear of the dying process; (2) listening to the patient’s expectations and wishes about the end of life; (3) giving attention to patient’s wishes about the design of the farewell; (4) offering rituals if the patient experiences them as meaningful; (5) listening to the stories, dreams and passions of the patient; (6) helping the patient find strength in inner resources; (7) connecting with the patient in truth, openness and honesty; (8) supporting communication and quality of relationships; (9) making sure the patient feels comfortable and safe; (10) seeing spirituality as an interwoven, though specific dimension; (11) caring for your own spirituality; (12) knowing and accepting your vulnerability; (13) being able to learn from your patient; and (14) having an interdisciplinary team that is there when needed.ConclusionsThe experts agreed to the 14 main elements of spiritual care in palliative home care. There were no differences in this regard between the stakeholder groups. This study provides a first step towards the development of an interdisciplinary spiritual care model in palliative home care.

Corticosteroids for sore throat: a clinical practice guideline

What is the role of a single dose of oral corticosteroids for those with acute sore throat? Using the GRADE framework according to the BMJ Rapid Recommendation process, an expert panel make a weak recommendation in favour of corticosteroid use. The panel produced these recommendations based on a linked systematic review triggered by a large randomised trial published in April 2017. This trial reported that corticosteroids increased the proportion of patients with complete resolution of pain at 48 hours. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides the recommendation together with an overview of the absolute benefits and harms of corticosteroids in the standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article. Clinicians and their patients can find consultation decision aids to facilitate shared decision making in MAGICapp (www.magicapp.org/goto/guideline/JjXYAL/section/j79pvn).

Outcome measures of spiritual care in palliative home care: a qualitative study.

The purpose of this study was to identify key outcome measures of spiritual care in palliative home care. A qualitative study was conducted with experts from 3 stakeholder groups (physicians, professional spiritual caregivers, and researchers) representing 2 countries (Belgium and The Netherlands). Three key outcome measures were identified: the extent to which the patient feels that he or she is being heard and taken seriously, the extent to which the patient experiences that there is a place for that which is insoluble, and the extent to which the patient experiences that there is a place for that which cannot be said. Further research is needed to implement and evaluate these new outcome measures.

Spiritual history taking in palliative home care: A cluster randomized controlled trial

Background: Many health-care providers experience barriers to addressing spiritual needs, such as not having the right vocabulary. The ars moriendi model might be a feasible tool for spiritual history taking in palliative care. Aim: To investigate the effect of a structured spiritual history taking on the spiritual well-being of palliative patients in home care. Design: Cluster randomized controlled trial, conducted between February and October 2013. Patients and methods: Registered nurses and general practitioners approached eligible patients with an incurable, life-threatening disease for study participation. Health-care providers allocated to the intervention arm of the study took a spiritual history on the basis of the ars moriendi model. Health-care providers in the control arm provided care as usual. Patient-reported outcomes on spiritual well-being, quality of life, pain, and patient–provider trust were assessed at two points in time. Results: A total of 245 health-care providers participated in the study (204 nurses and 41 physicians). In all, 49 patient–provider dyads completed the entire study protocol. The median age of the patients was 75 years (range: 41–95 years), and 55% of the patients were female. There were no significant differences at any point in time in the scores on spiritual well-being, quality of life, pain, or patient–provider trust between the intervention and the control group. Conclusion: This cluster randomized controlled trial showed no demonstrable effect of spiritual history taking on patient scores for spiritual well-being, quality of life, health-care relationship trust, or pain. Further research is needed to develop instruments that accurately assess the effectiveness of spiritual interventions in palliative care populations.

Vulnerability of wives of Nepalese labor migrants to HIV infection: Integrating quantitative and qualitative evidence

ABSTRACT HIV risk is determined by the interaction between social and individual risk factors, but information about such factors among Nepalese women is not yet understood. Therefore, to assess the risk factors and vulnerability of the wives of Nepalese labor migrants to HIV infection, the authors conducted a mixed-methods study in which a descriptive qualitative study was embedded within a case-control study. Two hundred twenty-four wives of labor migrants were interviewed in the case-control study, and two focus group discussions (n = 8 and 9) were conducted in the qualitative study. The authors found that illiteracy, low socio-economic status, and gender inequality contributed to poor knowledge and poor sexual negotiation among the wives of labor migrants and increased their risk of HIV through unprotected sex. Among male labor migrants, illiteracy, low socio-economic status, migration to India before marriage, and alcohol consumption contributed to liaisons with female sex workers, increasing the risk of HIV to the men and their wives through unprotected sex. Both labor migrants and their wives feared disclosure of positive HIV status due to HIV stigma and thus were less likely to be tested for HIV. HIV prevention programs should consider the interaction among these risk factors when targeting labor migrants and their wives.

Improving care for heart failure patients in primary care, GPs' perceptions: a qualitative evidence synthesis

Objectives General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs’ perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement. Design Qualitative evidence synthesis. Methods Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programmes checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis. Results Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs’ uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration. Conclusions The main challenges identified in this synthesis were how to deal with GPs’ uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs’ HF care were identified.

How do general practitioners use 'safety netting' in acutely ill children?

ABSTRACT Background: ‘Safety netting’ advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on ‘red flag’ features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding ‘safety netting’ procedures. Objectives: To explore how GPs apply ‘safety netting’ in acutely ill children in Flanders. Methods: We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components. Results: Although unfamiliar with the term, GPs perform ‘safety netting’ in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate ‘red flag’ features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive ‘safety netting’ as an important element of the consultation, acknowledging personal and parental limitations, such as parents’ interpretation of their advice. GPs do not feel a need for any form of support in the near future. Conclusion: GPs apply ‘safety netting’ intuitively and tailor the content. Further research should focus on the impact of ‘safety netting’ on morbidity and how the advice is conveyed to parents.

Somberheid in de palliatieve fase

SamenvattingWarmenhoven F, Vermandere M, Lucassen P, Vissers K, Aertgeerts B, De Lepeleire J. Somberheid in de palliatieve fase. Huisarts Wet 2014;57(5):236–8. Dat patiënten in de palliatieve fase somber en verdrietig zijn, is normaal en begrijpelijk. De exclusief psychiatrische blik die zulke somberheid benoemt als ‘depressieve stoornis’, is in zo’n situatie verraderlijk. Zij kan beter verruild worden voor een bredere, ‘salutogene’ benadering die zich niet uitsluitend richt op klachten en risicofactoren, maar ook probeert krachtbronnen aan te boren die de patiënt helpen het verdriet een plaats te geven en ‘gezond te sterven’.AbstractWarmenhoven F, Vermandere M, Lucassen P, Vissers K, Aertgeerts B, De Lepeleire J. Depression in the palliative phase. Huisarts Wet 2014;57(5):236–8. It is normal and understandable that patients are depressed and sad during the palliative phase, so it is not always appropriate to view and manage this depression from the psychiatric perspective of ‘depressive disorder’. Instead, it might be better to use the broader ‘salutogenic’ approach, by which emphasis is less on symptoms and risk factors and more on finding sources of inner strength to enable the patient to acknowledge and accept their sadness and to ‘die well’.

Implementation of the ars moriendi model in palliative home care: A pilot study

Abstract Background Assessing the spiritual well-being of palliative patients is often perceived as difficult by professional caregivers. Previous research has shown that general practitioners would appreciate a directive for spiritual conversations, if this tool were not too structured and not too religious, and provided it proved to be useful in clinical practice. Aim To investigate the experiences of professional caregivers and patients with the ars moriendi model as a directive for spiritual conversations in palliative home care. Method Qualitative semi-structured interview pilot study in Flanders Results All professional caregivers (n = 7) experienced the ars moriendi model as a useful directive to talk about spirituality at the end of life. They stressed the importance of adjusting the questions to each patient, and of spreading the spiritual conversation over several contacts. The palliative patients (n = 4) appreciated the conversation and advised the caregivers to show an open attitude, to spend enough time on their spiritual well-being, and to follow them in their spiritual process. Both caregivers and patients emphasized the importance of a trusting relationship to establish spiritual conversations. Conclusion Flemish professional caregivers experienced the ars moriendi model as useful for supporting spiritual conversations, provided that the model is used in a spontaneous and intuitive way, according to the needs of the patient. Palliative patients are stimulated by the questions in the model to think about their spiritual needs and resources.