Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial.

BACKGROUND: Although evidence increasingly demonstrates the effects of advance care planning, the relevant studies are of questionable quality, and lack consensus regarding when and with whom to initiate the conversation. OBJECTIVE: To examine the effects of a structured, nurse-led post-discharge advance care planning programme on congruence between the end-of-life care preferences of the patient and family members, decisional conflicts and the documentation of care preferences. DESIGN: A two-arm parallel-group randomised controlled trial. PARTICIPANTS: A total of 230 dyads comprising community-dwelling patients screened by the Gold Standards Framework Prognostic Indicator Guidance and their designated family members. METHODS: Patients in the experimental group participated in a structured advance care planning programme administered by a trained nurse during three weekly home visits following hospital discharge. In contrast, the post-discharge home visits provided to the control group focused on self-care management as attention control. The study outcomes were the dyadic congruence regarding end-of-life care preferences, the patients' level of decisional conflict regarding end-of-life decision-making and the documentation of these preferences at baseline and 1 and 6 months after enrolment. Generalised estimating equation models were used to compare changes in the outcomes between the groups across time. RESULTS: At baseline, few participants had ever heard of advance directives (12/460, 2.6%) and few patients had ever discussed end-of-life issues with family members (34/230, 14.8%). After six months, the experimental group exhibited a greater increase in dyadic congruence regarding various end-of-life care preferences than the control group (Ps < 0.04). The experimental group also exhibited a greater improvement in decisional conflict at 6 months relative to the control group (P = 0.003). However, the groups did not differ significantly in terms of changes in any outcomes after one month. The experimental group had significantly higher rates of completion of advance directives and electronic medical record documentation of do-not-attempt cardiopulmonary resuscitation orders than the control group. CONCLUSIONS: This study showed that a nurse-led structured advance care planning programme could effectively improve dyadic congruence regarding end-of-life care preferences, reduce patients' decisional conflict and increase the documentation of care preferences. The findings underscored the importance of supporting nurses to introduce advance care planning at an earlier time that enable patients with sufficient time to contemplate end-of-life issues, empower patients to deliberate their choices and engage patients and their family members in open discussion.

Impact of Death Work on Self: Existential and Emotional Challenges and Coping of Palliative Care Professionals.

Palliative care professionals, such as social workers, often work with death and bereavement. They need to cope with the challenges on "self" in working with death, such as coping with their own emotions and existential queries. In this study, the authors explore the impact of death work on the self of palliative care professionals and how they perceive and cope with the challenges of self in death work by conducting a qualitative study. Participants were recruited from the palliative care units of hospitals in Hong Kong. In-depth interviews were conducted with 22 palliative care professionals: five physicians, 11 nurses, and six social workers. Interviews were transcribed to text for analysis. Emotional challenges (for example, aroused emotional distress from work) and existential challenges (for example, shattered basic assumptions on life and death) were identified as key themes. Similarly, emotional coping (for example, accepting and managing personal emotions) and existential coping (for example, rebuilding and actualizing life-and-death assumptions) strategies were identified. This study enhances the understanding of how palliative care professionals perceive and cope with the challenges of death work on the self. Findings may provide insights into how training can be conducted to enhance professionals' self-competence in facing these challenges.

The effect of patient education with telephone follow-up on wound healing in adult patients with clean wounds: a randomized controlled trial.

PURPOSE: The purpose of this study was to determine the influence of clean dressing technique in a home-care setting following a patient education program and telephone follow-up in a group of adult patients to wound healing in patients managed by sterile dressing changes by professional nurses in a general care outpatient clinic. DESIGN: Randomized controlled trial. SUBJECTS AND SETTING: The sample comprised adult patients with clean wounds who attended a general outpatient clinic in the Kowloon East district, a densely populated urban area in Hong Kong. Sixty-five subjects were randomly allocated to the intervention group and 61 were allocated to the control group. INSTRUMENT: The Bates-Jensen Wound Assessment Tool (BWAT) was used to measure progress toward wound healing. METHODS: We compared a control group of patients who received normal wound care (sterile dressing changes by professional nurses in a nonspecialized outpatient clinic) to a group of adult patients who managed their wounds using clean technique for dressing changes in their home following education on wound care. The intervention group also received follow-up telephone calls on days 1 and 3. The BWAT was completed to assess the wounds of both groups on the patients' first attendance and once a week until their wounds had healed. RESULTS: Analysis revealed no significant differences between groups based on demographic or pertinent clinical characteristics. The mean BWAT score decreased in 2 weeks, from 27.26 to 15.15 (Freidman test, χ= 26.00, P < .000) for the intervention group and from 27.11 to 17.15 (Freidman test, χ= 24.15, P < .000) for the control group. A Mann-Whitney U test was used to compare the differences between the 2 groups based on total BWAT score. No statistically significant differences were found when groups were compared at baseline (Z =-0.416, P = .678), week 1 (Z =-1.313, P = .189), or week 2 (Z =-0.905, P = .418). CONCLUSION: No differences in wound healing were found when patients who dressed their wounds at home using clean techniques versus patients who had their wounds dressed with sterile technique by professional nurses in a general outpatient clinic.

The meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong.

AIM: This article reports a study to examine the meaning of hope from the perspective of Chinese advanced cancer patients in Hong Kong. METHODS: Semi-structured interviews were conducted with a convenience sample of advanced cancer patients recruited from the palliative care unit of a local hospital. Data were saturated after 17 participants were interviewed. Qualitative content analysis was adopted to analyse the data. FINDINGS: Hope as experienced by the participants was found to consist of five components: living a normal life, social support, actively letting go of control, reconciliation between life and death, and wellbeing of significant others. CONCLUSIONS: While hope is related to the wellbeing of patients with advanced cancer, successful palliative care partly depends on an awareness of the importance of hope in the end-of-life context and cultural sensitivity to the meanings behind it from the patients' own perspective.

Health-care professionals' perspective on hope in the palliative care setting.

Hope is considered a coping strategy as well as a factor that enhances quality of life for patients with advanced cancer. Most studies on the meaning of hope are from the patients' perspective. However, the health-care professionals' view is also important since it may affect their practice. This study explored the meaning of hope to patients with advanced cancer from health-care professionals' perspective. This was a qualitative study that used a hermeneutic phenomenological approach. Five focus group interviews were conducted with 23 participants including physicians, nurses, social workers, occupational therapists, chaplains, and a physiotherapist working in the palliative care unit of a hospital in Hong Kong. Data analysis revealed four themes: expected hopelessness, a dynamic process of hope, hope-fostering strategies, and peace as the ultimate hope. It appears that health-care professionals' hopefulness contributes to the hopefulness of patients. Opportunities to reflect on their values, beliefs, and experience may help health-care professionals enhance their ability to foster hope in patients.

Healthcare professionals' perceptions of existential distress in patients with advanced cancer.

AIM: This paper is a report of an exploration of the phenomenon of existential distress in patients with advanced cancer from the perspectives of healthcare professionals. BACKGROUND: Existential distress is an important concern in patients with advanced cancer; it affects their well-being and needs to be addressed in the provision of holistic care. METHOD: Focus groups were conducted from November 2008 to February 2009 with physicians, nurses, social workers, occupational therapists, physiotherapists, and chaplains working in a palliative care unit that served patients with advanced cancer in Hong Kong. Data collection and analysis were guided by the grounded theory approach. All categories were saturated when five focus groups had been held with a total number of 23 participants. FINDINGS: We found three causal conditions of existential distress: anticipation of a negative future, failure to engage in meaningful activities and relationships, and having regrets. Three basic (caring, relating and knowing) and six specific (positive feedback, religious support, new experiences, task setting, exploring alternatives and relationship reconciliation) intervening strategies were identified. Whether the intervening strategies would be effective would depend on patients' openness and readiness; healthcare professionals' self-awareness, hopefulness, and interest in knowing the patients; and a trusting relationship between patients and healthcare professionals. A sense of peace in patients was considered a consequence of successful interventions. CONCLUSION: This paper acknowledges the lack of an accepted conceptual framework of existential distress in patients with advanced cancer. It is based on healthcare professionals' views, and further studies from the perspectives of patients and their families are needed.