Critical Analysis on Palliative Care

Topic:

Determining the effectiveness of nursing home-based palliative care for patients with terminal illness as compared to home-based care in improving quality of life

PICOT Statement

Population: Patients with terminal illness

Intervention: Nursing home-based palliative care

Comparison: Home based palliative care

Outcomes: Increased quality of life

Time-Frame: Last 3 months

Research Question

Does nursing home-based palliative care among the patients with terminal illness increase the quality of life compared to home based care?

Research Critiques

1. Qualitative Research Critique

Proot, I. M., Abu‐Saad, H. H., Crebolder, H. F., Goldsteen, M., Luker, K. A., & Widdershoven, G. A. (2003). Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity. Scandinavian journal of caring sciences, 17(2), 113-121.

Background of the Study

The paper involved a qualitative research that was conducted through a grounded theory interview-based study to establish the vulnerability of the family caregivers in terminal palliative care. The significance of the question is determined by indicating that in Netherlands, approximately 32000 patients with non-acute illness died annually and the number had been expected to move to 20% by 2015. These patients in most cases were under family caregivers and therefore important to establish the vulnerability that they faced in caring for the patients. The purpose of the study was to explore the experiences of the family caregivers, their needs at homecare, and the health services that they received. The study is indicating to have been part of a large-scale research project that aimed at establishing how to offer a good death to the patients by providing palliative care at home.

Research Questions

1. What are the experiences of the family caregivers of a terminally ill person at home with reference to needs for home care and health services?
2. What are the difficulties and needs of the family members of a palliative care patient with terminal-illness?

The purpose of the study and the research questions are well connected. The purpose of the study indicates the need to determine the experiences that family care givers had in taking care of the palliative care patients. The research questions offer a platform of ascertaining these experiences and expounding further into them to consider the difficulties and needs.

Method

The method used in the research was grounded theory of the qualitative research design to explore the needs and experiences of family members in taking care of a terminally ill person at home. The study was carried out through interviews with family members of the terminally ill patients who had a life expectancy of less than 3 months.  The research identified the need of using a grounded-theory for this study which exemplifies its importance. Ground theory is said deal with descriptions and perceptions of the respondents and respondents engaged in the study. For this reason, the researcher indicated that the concepts would not be gained from the literature. For that case, very few references have been used in the literature review. The researcher has used about five references as part of the literature review with most of these being qualitative studies. The oldest reference used is dated 1990 and which is qualitative in nature and thus can be relied upon.

Results of the Study

From the study, the researchers were able to acquire factors that could be associated with vulnerability. These factors were classified into the decreasing factors or the increasing factors. The family members were found to get fatigue and burnout in the course of giving care to the terminally person. The situation was found to make the family caregiver vulnerable not withstanding their courage and strength. They indicated the need to attain balance in offering the care. The vulnerability increasing factors found through the study included care burden, restriction in activities, fear, insecurity, loneliness, facing death, and lack of support. The vulnerability decreasing factors found to include continuous previous activities, hope, keeping in control, satisfaction, and good support.

The results of the study had implications to the nursing as it highlighted the factors where the family care givers might require assistant on to ensure that they continue offers the best care to the patient. The nursing professions in the discussion were found no to be sensitive enough to the role of the family in palliative care. This implies that the study presented a wake-up call for the nursing staff to enhance their collaboration with the family caregivers. The role of the professional healthcare staff was considered to be instrumental to the family care givers in terms of giving them emotional and psychological support. Being ignorant of the needs of the family members palliative care was noted that it could cause the inadequate provision of care, it for this reason that the health care professional is called upon to increase their awareness that the family care givers are an important object of the care and support.

The study contributed to knowledge to the nursing world by highlighting the plight of the family care givers who are important element of palliative care but have for long been ignored with their needs disregarded. The study indicated the vulnerable position that these family care givers are in and how badly they needed the attention of the professionals operating in the terminal home care. The research added into the research knowledge by providing more information on vulnerability. Vulnerability has been indicated as being different from being powerless. The family members are said to be vulnerable due to the important role that they play in the care of the terminally ill patient. Vulnerability was indicated not as the direct opposite of autonomous but found to go hand in hand. The study pointed to the significance of the family care givers being cognizant of the need of care as well as being aware of the accompanying vulnerability. This knowledge is important in impact the planning for palliative care for patients with terminal illness as the patients would be included in the planning stages to ensure that the risk of burnout and fatigue is addressed at an early stage. The study was also relevant in pointing other relevant areas where more work was required especially in educating and training the professional on how to handle the vulnerable positions of the families caring for the terminally ill patients. It also indicates the need to identify the family members engaged in offering the care and search for ways to actively engage them.

Ethical consideration

The research project was approved by the ethics committee of the Maastricht University Hospital. The participants were selected by their general practitioners. One ethical consideration that was present in the study was need for informed consent for the participants. This indicates that the participants were made aware of their rights of being recorded which is one key component of the ethical standards required in an interview. The article does not indicate how it dealt with the ethical component on confidentiality that dealt with treatment of patient’s privacy.

Conclusion

The study indicate vulnerability among the care givers of patients with terminal illness ads crucial in attaining a balance between the care burden and capacity of the caregivers to cope. This was an echo to the thesis statement that had indicated the aim of the study as seeking to establish the balance between the burden and capacity by exploring the experiences of the family care givers. The experiences discussed in the study was important pointer to the health profession on the need to engaged the family members in the palliative care. The study findings are essential in nurse practice as it points to the need of family care givers attaining continuous balance between care burden and capacity to cope. In nursing practice, the information from the findings to the need of nurses established how factors affecting vulnerability of caregiver may have on the different care plans they may be proposing to the patients. The study emphasized on the importance of the care givers on palliative care and they should be well advised. The finding portrays the need for nursing practice to offer professional home care to the family caregivers.

• Quantitative Research Critique

Brumley, R., Enguidanos, S., & Hillary, K. (2003). Effectiveness of Home-Based Palliative Care Program for End-of-Life. Journal of Palliative Medicine, 715-724.

Background of the Study

The article involves a quantitative study carried out to determine the effectiveness of a home-based palliative program for end-of-life care. The study observed how the need to improve healthcare for Americans in their senior years has gained increased focus in the past decade. It has noted how the baby boomers have joined the elderly population in large numbers which has increase burden to the healthcare system. The population in United States is estimated to be comprised of about 12.5% of the old population and with this number expected to be on the rise. It is estimated the less than 5% of the Medicare die annually, but the medical costs for the last year of life for this group amounts to 25% of the total annual costs. The clinical problem addressed by this article is on how the current constraints put in place by Medicare regulations have created barriers to developing modes of palliative care for the terminally and chronically ill patients (Brumley, Enguidanos, & Hillary, 2003).

The significance of the study is noted by indicating how the barriers associated with Medicare regulations and other barriers such as patients refusing hospice care, uncertainty in establishing life expectancy of the patients, patients’ unwillingness of undertaking curative care and negative image of hospice care contributes to patient’s care while in acute care units and intensive care unit even after receiving medically futile care. This significance is elaborated using statistics that indicated that in South California TriCentral Area 63% of patients in ICU and 54% of those who died in medical or surgical units had terminal or chronic illness (Brumley, et al., 2003).

The purpose of the study was to establish the effectiveness TriCentral Palliative Care Program, which is an end-of-life care plan and establish how the help serve the patients better. The research question that the study aims to achieve is on “Are palliative care patients more satisfied with the TriCentral Palliative Care Program and thereby lead to use of fewer medical service as compared to patients receiving the traditional end-of-life?” The purpose of the study and its research problem are connected. While the purpose of the study intended to establish the effectiveness of the TCPC program, the research question offered a means of establishing this effectiveness by seeking to make a comparison of patients’ satisfaction level using either the TCPC or the traditional end-of-life program.

Methods of the Study

The study design adopted for the study included a nonequivalent comparison group design where data from the control group was compared with that of the intervention group. The importance of engaging in this study was noted the be associated with the facilitation of the process of evaluation how the program achieved complex physical, emotional, social and spiritual need of end-of-life patients. The study was approved by the Kaiser Permanente Southern California Human Subject Protection Committee. It is clear that the study was through voluntary participation as patients have the option of declining where it is noted that 73 eligible patients declined being interviewed (Brumley, et al., 2003).

Data was collected through phone interviews seven days after enrollment and 60 minutes thereafter. The main variables data gathered for the study included demographic data, patient’s rating of their illness severity, quality of life, and satisfaction of services offered. The satisfaction data was collected using the Reid-Gundlach Satisfaction instruments and yielded three categories where overall satisfaction was measured. Service utilization data was gathered from KP administrative databases. The costs effectiveness of the program was measured by evaluation of the staff costs only.

Part of data management process for the study involved organizing the intervention and comparison group in a manner that data from each group would be comparable. This was achieved by putting in place selection criterion that ensured comparison among groups of patients at end-of-life. Data analysis included the use of post hoc students t-tests for individual dependent variable to establish group differences. Multiple regression was used to establish the portion of costs that could be explained by control group. The rigor of the process was assured through the use of statistical software such SPSS statistical software and LIMDEP data analysis software package. Reduction of the research bias was carried out through the control of statistically significant between group differences were controlled as covariates. Multivariate analysis variance (MANCOVA) was used to control Type I error associated with multiple tests (Brumley, et al., 2003).

Results of Study

Results on high patient satisfaction indicated absence of any statistical significance in mean satisfaction scores between intervention and comparison groups. It was observed that at baseline, the satisfaction was high for both groups. After 60 days enrollment the satisfaction level among the intervention group increased significantly from baseline while that of comparison group remained the same (Brumley, et al., 2003). More patients were found to die among the intervention group in comparison to control group. The results on effective cost management indicated that among the intervention group there were fewer emergency department visits, inpatients days, skilled nursing days, and physician office visits relative to the comparison groups. However, the intervention group had more care visits than the comparison groups. There was cost reduction across diagnoses but more significant for patients with cancer.

The results of this study pointed to the fact that enrollment of care model produced lower costs of care and higher patient satisfaction relative to the traditional care. The findings can be said to be an accurate reflection of reality based on the fact that the TCPC program was an innovative program designed to offer healthcare services to chronically and terminally ill patients. This implied that the program was structured to specifically the needs of these patients by ensuring the gradual transition from curative focus to increasing palliative measure. The study was found to have huge implications for healthcare practice. The study identified that the model being analyzed caused a 45% decrease in cost of services offered to palliative care patients (Brumley, et al., 2003). The study also pointed to how end-of-life was not a preference among patients which saw most patients die in hospitals despite their wish to die at home. The program analyzed offers an ethical alternative to traditional end-of-life care for nurse’s practitioners to apply in a manner that allows the patients an opportunity to die without pain and yet in comfort of their own home. The results in the reduced need of for specialized care among the patients using TCPC program and high satisfaction levels offers a recommendation that care can effectively be transferred from hospital setting to home environment. An unexcepted benefit that could affect the nursing practice was on increased heightened consciousness and acquisition of enhanced end-of-life skills by health care practitioners (Brumley, et al., 2003).

One limitation of the study was found to be on its research design which did not offer an exhaustive means of testing the model. The possibility of generalizing the model to others sites was found to be limited because the study took place in closed system with sample acquired only from South Carolina. The article indicated the need of using randomized studies in the testing of the model and offering more strengthening the validity of the findings. The article indicated the need for multisite studies to evaluate the generalizability of the model to other systems and populations. The article was presented in a logical coherent logic with results progressively building on each other.

Ethical Consideration

The study was approved by the Kaiser Permanente Southern California Human Subject Protection Committee. The article does not specify how the patient privacy was protected. The only ethical consideration regarding the treatment indicated was on voluntary participation. This can be observed from the fact that for the study 558 participants were enrolled from which 73 eligible patients declined the engage in the study (Brumley, et al., 2003).

Conclusion

The thesis statement indicated that palliative care patients using the TriCentral Palliative Care (TCPC) would be more satisfied with their healthcare and use less medical services than the patients receiving traditional end-of-life medical care. This thesis statement indicates an innovative approach meant overcome the barriers associated with Medicare regulations and other barriers associated with the traditional palliative care. The TCPC program being assesses is an interdisciplinary home-based program for patients at end of life. It offers enhanced pain control, symptom management, and psychosocial support with an aim of improving the quality of life and care and thereby reduce the total costs of care. The study was carried out through a non-equivalent comparison group design where the patients the intervention group were subjected to TSPC program and the control group with the traditional end-of-life care. The results of this study pointed to the fact that enrollment of care model produced lower costs of care and higher patient satisfaction relative to the traditional care. The program represented how end of life care should experience gradual transition from curative focus to increasing palliative measure.

This study has implication in nursing practice in that it provides an end-of-life program with capability of reducing cost by 45%, offers an ethical alternative to traditional end-of-life care for nurses’ practitioners to apply, points out to the fact that the palliative care can be transferred from hospital to home environment thereby improving satisfaction, and the program offers an opportunity for healthcare practitioners to improve their skills on palliative care. This implies that the nurses would need to understand the proposed ethical alternative palliative care program. This would change the manner in which the nursing practice is carried out under the traditional end-of-life care.

Proposed Evidence-Based Practice Change

The link between PICOT Statement, Research Articles and Nursing Practice Problem

The PICOT study indicates that the population to be used for the analysis would be patients with terminal illness. The proposed intervention would be nursing-home based palliative care, which would be compared to home-based palliative care plan to determine its effects in increasing the quality of life within a period of three months. The significance of this study can be established by conducting a review from the research articles. Brumley et al., (2003), indicated that the population in United States is estimated to be comprised of about 12.5% of the old population and with this number expected to be on the rise. It is estimated the less than 5% of the Medicare die annually, but the medical costs for the last year of life for this group amounts to 25% of the total annual costs. This was affirmed by Lusterbader et al., (2017), who indicated that the 5% of the sickest patients account for over 50% of total cost with most of these costs being accounted for in the final months and that hospital-based palliative care teams had proven to be helpful in improving the outcomes and cost savings. It is approximated that over 27 million people will need long-term care by 2050, with number of the aged in America expected to double in the next 25 years to hit approximately 72 million (Behm, 2015). In Netherlands, approximately 32000 patients with non-acute illness die annually and the number had been expected to move to 20% by 2015. A study by Brumley et al. (20070) indicated that almost 60% of deaths take place in the hospital despites most of these patients having stated their preference to die at home. The problem even affected children as estimates indicated that over 2000 children died of cancers related illness. From these research articles, it is thereby clear that the practice problem on palliative care as provided by in the PICOT Statement is a major issue that requires a more comprehensive analysis.

The results from the research articles provided a lot of information on the different care plans methods offered. In offering home-based care plans, it was indicated that that the quality of care that the family care-givers offered to the patients was affected by increasing and increasing factors to vulnerability that made the care givers get fatigue and burnout thereby affecting the quality of life experienced by the end-life patient (Proot et. Al, 2009). Lestrade et al, indicated that the home-based palliative care (HBPC) was associated with more significant cost savings, less need for hospitalization and increased used of the final months of life (2017). Analysis carried out Australia attest to this, using the Palliative Care Extended Packages at home, where it was determined that it increase the average days, lower death rate and increase net monetary benefit (Behm, 2015). Another study provided information about how in-home palliative car assisted in increasing patient satisfaction and costs based on the medical care at end of life. Based on evidence provided it is thereby justifiable to reforming end-of-care care (Brumley, 2007). In reference to children with need for palliative care, it was observed that children within PPC home care program, the children seemed to have more quality relative and are more likely to die at home.   It is therefore clear that some research articles were essential in attempting to establish the effectiveness between in-house and home-based palliative care.

Proposed Evidence-Based Practice Changes

The proposed evidence-based practice changes will be the introduction of on integrated palliative care plan which include both home-based and hospice-based care plans. Some practice changes within this project would include collaboration with community, re-training of care providers and engagement of long-term care institutions. The integrated model of palliative care will include a multi-discipline team comprised of registered nurses, social workers, data analyst and administrative staff. This team will use their strong clinical skills in palliative care and collaborate with the family care-giver in providing palliative care on an outpatient basis. It is noted that key features of successful program include provision of home-based care, involvement of person interactions, provision of geriatric assessment, caregiver support, palliative care skills and 24/7 clinical availability (Lustbader, 2017). (Behm, 2015), indicates that day-based hospice program and home-based palliative care are associated with improved quality of care.

References

Behm, B. (2015). A Synthesis of Home-based Palliative Care on Clinical Effectiveness, Cost-effectiveness and Quality of Life: Policy Implications Explored.

Brumley, R., ENguidanos, S., Jamison, P., Seitz, R., Morgenstern, N., Saito, S., . . . Gonzalez, J. (2007). Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-home Palliative Care. The American Geriatrics Society.

Brumley, R., Enguidanos, S., & Hillary, K. (2003). Effectiveness of Home-Based Palliative Care Program for End-of-Life. Journal of Palliative Medicine, 715-724.

Friedrichsdorf, S. J., Postier, A., Dreyfus, J., Osenga, K., Sencer, S., & Wolfe, J. (2015). Improved quality of life at end of life related to home-based palliative care in children with cancer. Journal of palliative medicine, 18(2), 143-150.

Lustbader, D., Mudra, M., Romano, C., Lukoski, E., Chang, A., Mittelberger, J., … Cooper, D. (2017). The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization. Journal of Palliative Medicine, 20(1), 23–28.

Proot, I. M., Abu‐Saad, H. H., Crebolder, H. F., Goldsteen, M., Luker, K. A., & Widdershoven, G. A. (2003). Vulnerability of family caregivers in terminal palliative care at home; balancing between burden and capacity. Scandinavian journal of caring sciences, 17(2), 113-121.