“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

Abstract Background: Acute functional decline is a common clinical syndrome in geriatric health care that is typically characterised by nonspecific symptoms and presents with a mix of physical, psychological, social and functional manifestations.Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated these systems in community health care.The purpose of this study is to describe the experiences of registered nurses (RNs) and general practitioners (GPs) when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline.Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. GPs and RNs were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method.Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs emphasised that MEWS supported the clinical reasoning and decision-making process. Additionally, those applying MEWS required comprehensive reasoning skills and specific knowledge of the patients. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability.Conclusion: MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and GPs’ work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements. MEWS trigger recommendations were experienced as inappropriate in the home care context. This study identifies the need for a modified, evidence-based EWS adjusted for geriatric patients in home care.

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Decision making in the end-of-life care of patients who are terminally ill with cancer – a qualitative descriptive study with a phenomenological approach from the experience of healthcare workers.

10.21203/rs.3.rs-155936/v1 ◽

2021 ◽

Author(s):

Angela Luna-Meza ◽

Natalia Godoy-Casasbuenas ◽

José Andrés Calvache ◽

Eduardo Diaz ◽

Fritz Gempeler ◽

...

Keyword(s):

Decision Making ◽

Palliative Care ◽

Home Care ◽

End Of Life ◽

End Of Life Care ◽

Life Care ◽

End Of Life Decisions ◽

Care Plans ◽

Qualitative Descriptive ◽

Imminent Death

Abstract Background: In Colombia, recent legislation regarding end-of-life decisions includes palliative sedation, advance directives and euthanasia. We analysed which aspects influence health professionals´ decisions regarding end-of-life medical decisions and care for cancer patients.Methods: Qualitative descriptive–exploratory study based on phenomenology using semi-structured interviews. We interviewed 28 oncologists, palliative care specialists, general practitioners and nurses from three major Colombian institutions, all involved in end-of-life care of cancer patients: Hospital Universitario San Ignacio and Instituto Nacional de Cancerología in Bogotá and Hospital Universitario San José in Popayan. Results: When making decisions regarding end-of-life care, professionals consider: 1. Patient’s clinical condition, cultural and social context, in particular treating indigenous patients requires special skills. 2. Professional conditions: training in palliative care and experience in discussing end-of-life options and fear of legal consequences. Physicians indicate that many patients deny their imminent death which hampers shared decision-making and conversations. They mention frequent unclarity regarding who initiates conversations regarding end-of-life decisions with patients and who finally takes decisions. Patients rarely initiate such conversations and the professionals normally do not patients directly for their preferences. Fear of confrontation with family members and lawsuits leads doctors to carrying out interventions such as initiating artificial feeding techniques and cardiopulmonary resuscitation, even in absence of expected benefits. The opinions regarding the acceptability of palliative sedation, euthanasia and use of medications to accelerate death without the patients´ explicit request vary greatly. 3. Conditions of the insurance system: limitations exist in the offer of oncology and palliative care services for important proportions of the Colombian population. Colombians have access to opioid medications, barriers to their application are largely in delivery by the health system, the requirement of trained personnel for intravenous administration and ambulatory and home care plans which in Colombia are rare.Conclusions: to improve end-of-life decision making, Colombian physicians and patients need to openly discuss wishes, needs and care options and prepare caregivers. Promotion of palliative care education and development of palliative care centres and home care plans is necessary to facilitate access to end-of-life care. Patients and caregivers’ perspectives are needed to complement physicians’ perceptions and practices. Key Message: The results highlight the importance of improving access to end-of-life care in Colombia, and diminish the “denial of imminent death” among patients and caregivers to facilitate end-of-life discussions and shared decisions; interventions to prepare caregivers and promote home care.

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Belgian General Practitioners' Perspectives on the Use of Palliative Sedation in End-of-Life Home Care: A Qualitative Study

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2013.06.016 ◽

2014 ◽

Vol 47 (6) ◽

pp. 1054-1063 ◽

Cited By ~ 17

Author(s):

Maria Sercu ◽

Peter Pype ◽

Thierry Christiaens ◽

Anselme Derese ◽

Myriam Deveugele

Keyword(s):

Qualitative Study ◽

Home Care ◽

End Of Life ◽

General Practitioners ◽

Palliative Sedation

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Applying the Modified Early Warning Score (MEWS) to assess geriatric patients in home care settings: A qualitative study of nurses’ and general practitioners’ experiences

10.21203/rs.2.16666/v1 ◽

2019 ◽

Author(s):

Kristin Jeppestøl ◽

Line Kildal Bragstad ◽

Marit Kirkevold Kirkevold

Keyword(s):

Decision Making ◽

Home Care ◽

Registered Nurses ◽

General Practitioners ◽

Clinical Reasoning ◽

Early Warning ◽

Geriatric Patients ◽

Functional Decline ◽

Early Warning Score ◽

Design Data

Abstract Background : Acute functional decline is a common clinical syndrome in geriatric health care and is typically characterised by nonspecific symptoms and presentations with a mix of physical, psychological, social and functional manifestations. Early warning score (EWS) systems are widely implemented in nursing homes and home care to detect clinical deterioration. The effects of EWS systems have been thoroughly evaluated in hospital care settings, but few studies have evaluated EWS systems in community healthcare. The purpose of this study was to describe the experiences of registered nurses and general practitioners experiences when using the Modified Early Warning Score (MEWS) to support clinical reasoning and decision-making with geriatric home care patients who suffer from acute functional decline. Method: A qualitative methodology was used with a descriptive exploratory design. Data were collected from seven focus group interviews. General practitioners (GPs), and registered nurses (RNs) were purposively sampled from large, medium and small municipalities in Norway. Data were analysed using an inductive content analysis method. Results: MEWS was used as an additional decision-making tool with elderly home care patients when acute functional decline was detected. RNs and GPs highlighted that MEWS supported the clinical reasoning and decision-making process. Additionally , comprehensive reasoning skills and specific knowledge of the patients were needed. RNs identified the need for contextual adjustments to the use of MEWS in home care settings. Implementing MEWS has improved the collaboration and clinical practice of RNs and GPs. The adherence to MEWS follow-up recommendations was adjusted to the home care setting, accounting for potentially limited medical availability. Conclusion : MEWS supported RNs and GPs in conducting comprehensive clinical assessments and reasoning when acute functional decline was detected. Interdisciplinary communication and collaboration appeared to be strengthened, and the GP's work was streamlined. Several limitations were identified with the use of MEWS reference values with geriatric patients, which could lead to ambiguity and misjudgements . MEWS trigger recommendations were experienced as inappropriate to comply within home care. This study identifies the need for a modified evidence-based EWS adjusted for geriatric patients in home care.

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A Literature Review of Possible Barriers and Knowledge Gaps of General Practitioners in Implementing Advance Care Planning in Ireland: Experience from Other Countries

International Journal of Medical Students ◽

10.5195/ijms.2021.567 ◽

2021 ◽

Vol 9 (2) ◽

pp. 145-149

Author(s):

Karendeep Somal ◽

Tony Foley

Keyword(s):

Decision Making ◽

End Of Life ◽

General Practitioners ◽

Care Plan ◽

Knowledge Gaps ◽

Decision Making Capacity ◽

Advance Care Plan ◽

Advance Care ◽

Critical Appraisal Skills ◽

Eol Care

An Advance Care Plan (ACP) is a process of decision-making concerning end of life care that embodies a patient’s values and wishes, for a time when patients are unable to make such decisions for themselves. ACPs have been employed into medical practices worldwide; however, they remain largely uncompleted by general practitioners (GPs), regardless of their benefits to patients and their families with respect to end of life (EOL) care. Furthermore, ACPs will soon be implemented into clinician practices across Ireland, as part of the Assisted Decision Making (Capacity) Act 2015. This review aims to explore the literature to examine challenges GPs may face in employing ACPs into clinical practice. An electronic search was performed through three databases: PubMed, MEDLINE, and CINAHL Plus, through which a total of eleven studies met the selection criteria. Additionally, three studies were provided by experts in the field. Thus, a total of fourteen studies were condensed and critically appraised through CASP (Critical Appraisal Skills Program), which concluded that the quality of the studies was high. Through this review, knowledge gaps and barriers for GPs regarding ACPs were identified. Barriers for implementing ACPs into practice were categorized into three major themes: barriers for the GP, barriers in the healthcare system, and barriers regarding the patient. These included insufficient time, complexity of the ACP documents themselves, uncertainty of the disease prognosis, and the ultimate fear of inducing anxiety and loss of hope in patients.

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