Abstract
Ko E, Kwak J, Nelson-Becker H: What constitutes a good death and bad death? Perspectives of homeless older adults. Death Stud 2015;39:422–432.
This qualitative study explored perspectives toward a good or bad death among 21 older homeless adults residing in transitional housing. Using grounded theory approach, the authors noted that the themes for a good death were (1) dying peacefully, (2) not suffering, (3) experiencing spiritual connection, and (4) making amends with significant others. Themes for a bad death were (1) experiencing death by accident or violence, (2) prolonging life with life supports, (3) becoming dependent while entering a dying trajectory, and (4) dying alone. Health care professionals need to develop approaches for end-of-life care grounded in understanding unique needs of older homeless adults.
Martz K: Actions of hospice nurses to alleviate guilt in family caregivers during residential care transitions. J Hosp Palliat Nurs 2015;17:48–55.
Transitioning elderly family members enrolled in hospice care to and between home, assisted-living facilities, and nursing home facilities at the end of life may induce a reciprocal type of suffering for both the elderly dying persons and their families. Glaserian grounded theory was used to examine how hospice nurses experienced and perceived caring for patients and their family caregivers during care transitions. A sample of 16 participants included 13 hospice nurses, 1 hospice social worker, 1 skilled nursing facility social worker, and 1 assisted living facility nurse. In addition, 4 nurses received follow-up interviews, and 2 theoretical interviews were conducted after the model was developed, with a total of 22 interviews. Findings described the actions of the nurses utilizing the situation-specific model of the basic social psychological process that families experience as a scaffold. Results revealed that actions that alleviated guilt included advocating, navigating the complexities of both facility systems and families, and especially coaching during the dying process. The author suggests that the results have educational implications for hospice nurses and interdisciplinary teams supporting family caregivers through these difficult transitions.
Morris SM, King C, Turner M, et al.: Family carers providing support to a person dying in the home setting: A narrative literature review. Palliat Med 2015;29:487–495.
This study was based on people dying at home relying on the care of unpaid family caregivers. There is growing recognition of the central role that family caregivers play and the burdens that they bear, but knowledge gaps remain around how to best support them. The aim of this study was to review the literature relating to the perspectives of family caregivers providing support to a person dying at home. A narrative literature review was chosen to provide an overview and synthesis of findings. The following search terms were used: caregiver, carer, terminal care, supportive care, end of life care, palliative care, domiciliary care, AND home AND death OR dying. During April to May 2013, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycINFO, PubMed, Cochrane Reviews, and Citation Indexes were searched. Results demonstrated that a total of 28 studies were included in the review. The overarching themes were family caregivers' views on the impact of the home as a setting for end-of-life care, support that made a home death possible, and the family caregiver's views on deficits and gaps in support and transformations to the social and emotional space of the home.
The authors conclude that many studies focus on the support needs of people caring for a dying family member at home, but few studies have considered how the home space is affected. Given the increasing tendency for home deaths, greater understanding of the interplay of factors affecting family caregivers may help improve community services.
Barjaktarevic I, Bobe L, Klapholz A, Dinan W: Multiple cardiopulmonary resuscitation attempts in a community hospital: Evaluation of the futility assessment. Am J Hosp Palliat Med 2015;32:504–509.
In hospital settings, inadequate recognition of futility of aggressive medical management in patients with terminal disease and lack of the timely transition to palliative care may lead to both excessive and potentially harmful treatment and unnecessary burden on hospital resources. In order to better understand the outcomes of futile medical management and recognize the need for more appropriate end-of-life care, the authors evaluated the survival of a particularly vulnerable cohort of patients in a community hospital who had survived at least one cardiorespiratory arrest (CRA) but whose medical problems led to subsequent arrests. In this retrospective cohort study, the authors reviewed the annual cardiopulmonary resuscitation (CPR) data in a community hospital in urban settings. Results demonstrated that of all patients who had CRA, 22.4% had more than one CRA episode and had multiple CPRs (42.0% of all inpatient CPR were performed on this group of patients). Overall survival at the discharge of patients who had single CRA is significantly better than survival at the discharge of patients who had more than one CRA episode (31.0% versus 4.5%). Only 18.5% of the patients who initially survived CPR after CRA were transitioned to “do not resuscitate” status subsequently, while the vast majority had continued aggressive resuscitative efforts. The authors conclude that adjusting medical care based on futility assessment in patients with chronic illness who survive CRA is often neglected, but is a crucially relevant step in the optimization of health care system management.
Combs SA, Davison SN: Palliative and end-of-life care issues in chronic kidney disease. Curr Opin Support Palliat Care 2015;9:14–19.
Patients with progressive chronic kidney disease (CKD) have high morbidity, mortality, and symptom burden. Cardiovascular disease (CVD) and congestive heart failure (CHF) often contribute to these burdens and should be considered when providing recommendations for care. This review aimed to summarize recent literature relevant to the provision of palliative and end-of-life care for patients with progressive CKD and specifically highlights issues relevant to those with CVD and CHF. The authors note that dialysis may not benefit older, frail patients with progressive CKD, especially those with other comorbidities. Patients managed conservatively (i.e., without dialysis) may live as long as patients who elect to start dialysis, with better preservation of function and quality of life and with fewer acute care admissions. Decisions regarding dialysis initiation should be made on an individual basis, keeping in mind each patient's goals, comorbidities, and underlying functional status. Conservative management of progressive kidney disease is frequently not offered but is likely to benefit many older, frail patients with comorbidities such as CHF and CVD. The authors conclude that a palliative approach to the care of many patients with progressive CKD is essential to ensuring they receive appropriate quality care.
Noreika DN, Coyne P: Discontinuance of life sustaining treatment utilizing ketamine for symptom management. J Pain Palliat Care Pharmacother 2015;29:37–40.
The authors present the case of an otherwise healthy 21-year-old female who developed severe respiratory failure following a minor procedure requiring extracorporeal membrane oxygenation (ECMO) and bilevel ventilation. During her protracted ICU course, she had significant difficulties with agitation and was titrated to the following regimen: hydromorphone 30 mg/hour, fentanyl 200 mcg/hour, dexmedetomidine 1.5 mcg/kg/hour, propofol at 70 mcg/kg/min, and midazolam at 20 mg/hour. The authors were consulted to assist in withdrawal of life-prolonging measures at the family's request, and given the high doses of commonly used opioid and sedative medications, successfully utilized methadone and ketamine for symptom control. This case study would indicate that in selected patients on high-dose opioid and sedative medications prior to withdrawal of life-prolonging measures, ketamine may be considered for symptom management.
Haug SH, Danbolt LJ, Kvigne K, Demarinis V: How older people with incurable cancer experience daily living: A qualitative study from Norway. Palliat Support Care 2015;13:1037–1048.
An increasing number of older people are living with incurable cancer as a chronic disease, requiring palliative care for shorter or longer periods of time. The aim of this study was to describe how older people experience daily living while receiving palliative care in specialized health care contexts. The authors conducted a qualitative research study with a phenomenological approach called “systematic text condensation.” A total of 21 participants, 12 men and 9 women, aged 70 to 88, took part in semistructured interviews. They were recruited from two hospitals in southeastern Norway. Results demonstrated that the participants experienced a strong link to life in terms of four subthemes: to acknowledge the need for close relationships; to maintain activities of normal daily life; to provide space for existential meaning-making, and to name and handle decline and loss. In addition, they reported that specialized health care contexts strengthened the link to life by prioritizing and providing person-centered palliative care.
The authors conclude that older people with incurable cancer are still strongly connected to life in their daily living. The knowledge that the potential for resilience remains despite aging and serious decline in health is considered a source of comfort for older people living with this disease. Insights into the processes of existential meaning-making and resilience are seen as useful in order to increase our understanding of how older people adapt to adversity, and how their responses may help to protect them from some of the difficulties inherent to aging. Health care professionals can make use of this information in treatment planning and for identification of psychosocial and sociocultural resources to support older people and to strengthen patients' life resources.