Results Of CAREFuL Program In Geriatric Wards In Flemish Region Of Belgium And Opinions On Symptoms Management, Nutrition, And Hydration From PeolcPSP Survey In The United Kingdom Essay.

Purpose of assessment task 1 Symptom management in the setting of palliative or end-of-life care is an integral aspect of nursing care. Unnecessary harm and reduced quality of life are avoidable consequences of inadequate symptom management. The purpose of this assessment task is for you to explore, interpret and understand current research evidence regarding symptom management and its effectiveness.

In this assignment you will be required to read two (2) peer reviewed articles describing primary research (references provided below), to provide annotated information for each article and to use the knowledge you have gained from reading the articles to explain how these findings inform clinical nursing practice.

Study Type and Design

Is the title appropriate?	Yes. The article discusses implementing ways of improving the comfort of dying people as mentioned in the title.
Is there a structured abstract?	Yes.
Study Type	Quantitative analysis
Study Design	The study was conducted in ten hospitals by taking a cluster of randomized trials in geriatric wards. CAREFuL program was used in five of the hospitals and the other five were used as a control.
Was this Primary or Secondary research?	This was a primary study since the data was collected directly by the researchers.
Study Objective or Aims	Primarily this research assessed the comfort of patients around dying with and without the implementation of the CAREFuL programme.
The setting in which the study was conducted	The research was conducted on hospitals in Belgium (specifically Flemish Region) between October 2012 and March 2015
Inclusion / Exclusion Criteria	The hospitals in which the study was conducted had to be within Fleming and have a geriatric ward.
How was the data collected?	The researchers conducted an unstructured direct observation in which they collected the data by observing the parties under study.
What data was collected?	The data collected was on the care and comfort of the patients in geriatric wards according to the AIM- EOLD, and SM-EOLD.
How was the data analyzed?	The data was analyzed quantitatively based on the figures collected in the study after which conclusions were made.
What ethical considerations are associated with the research?	The privacy of the patients was respected and permission was sought from the relevant authorities.
Sample size – How many participants were included in the research?	In the research, 11% of the beds in all the hospitals (ten in number) were used in the analyzing the situation. The pair of hospitals was divided into two groups in which one of them was used as a control for the other. The control group of hospitals was assigned to the standard healthcare practice. 118 patients were in the control hospitals. The other five hospitals, which had a total of 164 patients under study, were assigned to the CAREFuL Programme. The CAREFuL programme comprised of a comprehensive guide for taking care for patients in last stages of life, training for the nurses and the carers, supporting materials in form of documents and a guide on its implementation. The guide also made it possible for trained individuals to train other people on how to handle elderly patients with due compassionate and care. Patients and family members were masked to intervention allocation while the members of staff of the hospitals were unmasked. The primary focus of this research was to assess the comfort of patients around dying with and without the implementation of the CAREFuL programme. The assessments done for the control group involved 92% of the patients (109 out of 188 patients) and 80% of the patients in the CAREFuL were assessed (132 out of 164 patients) by nurses. Family cares did 19% (23 patients) of the assessments in the control group and 29% (48 patients) of the assessment in the CAREFuL group. Nurse-assessed comfort increased significantly with the implementation of CAREFuL than in the control group; (CAD- EOLD baseline-adjusted mean difference 4.30, 95% Cl 2.07-6.53; p<0.001. The results obtained nurses as per the SM- EOLD were as follows (−0·41, −1·86 to 1·05; p=0·58) while those obtained by family caregivers were as follows (−0·59, −3·75 to 2·57; p=0·71).
Was the sample size justified?	The sample size is justifiable since it was chosen randomly and the natural processes were not disrupted by the study.
Key Findings/ Results	Based on the findings the researchers concluded that the implementation of the CAREFuL programme will improve the care accorded to patients in their dying moments. The implementation of CAREFuL is projected to increase the comfort of patients with critical health conditions in the last days of their lives.

 

Is the title appropriate?	The title is entirely appropriate since the article discusses nutrition concerns and hydration of patients at dying moments as well as other issues as viewed by patients, relatives, and clinicians.
Is there a structured abstract?	The abstract is structured as it outlines the contents of the main article in the order in which they appear.
Study Type	This study is qualitative in nature.
Study Design	The study was conducted in various regions of the United Kingdom. The PeolcPSP issued 1403 questionnaires that were later uploaded to NVivo 10 as PDF files after which they were later typed into word documents and checked for accuracy and uploaded onto NVivo 10.
Was this Primary or Secondary research?	This was a secondary research on a study conducted by Palliative and end-of-life care Priority Setting Partnership (PeolcPSP).
Study Objective or Aims	The research explored respondents on issues to do with symptoms, hydration, and nutrition. The respondents in this study were relatives and medical professionals.
The setting in which the study was conducted	The study was conducted in the United Kingdom between December 2013 and May 2014.
Inclusion / Exclusion Criteria	The individuals that were involved in the study are those that had experience with palliative care and they were willing to participate in the survey.
How was the data collected?	Semi-structured questionnaires were conducted on all the respondents in which personal opinions were recorded too.
What data was collected?	The data that was collected is personal opinions on the management of symptoms such as agitation, pain, and fatigue.
How was the data analyzed?	The data were analyzed thematically using Braun and Clarke's approach.
What ethical considerations are associated with the research?	The consent of the respondents was sought first and all the people who responded to the questions did it on free will.
Sample size – How many participants were included in the research?	The PeolcPSP data (n=1403) involved 190 respondents and it was coded by a team of researchers. The respondents gave their views on hydration, nutrition, and symptoms.
Was the sample size justified?	The sample is justifiable since it covered all the regions of the United Kingdom and the respondents were allowed to give their personal opinions since the questions were open-ended.
Key Findings/ Results	Symptoms management is critical in palliative care. A review of 143 people with symptoms such as pain, fatigue, worry, anorexia, and dyspnea had more than 50% prevalence. The management of these symptoms can be done effectively by following the guidelines of the National Institute for Health and Care Excellence (NICE).  The allocation of little funds for research in palliative in comparison to research on matters such as the research on cancer care is one of the reasons behind the poor management of symptoms. Professionals in palliative care should, therefore, utilize the existing research. Competencies of professionals were also questioned on critical issues such as pain management in end-of-life stages since most of the respondents expressed their concern about the pain that their relatives were going through. This was reported to cause questioning of professionals by the respondents on issues such as administration of analgesia. Suggestions emphasized on the need for timely pain management such as the use of Skype to assess patients instead of home visits. Some respondents also highlighted the place of care as a determinant of the comfort of the patient. Non-palliative environments were reported to be better for patients since the caregiver accorded undivided attention to the patient. Both medical professionals and relatives agreed to the fact respiratory secretions are poorly managed. Enteral nutrition was also identified as a source of patient agitation. Thirst due to lack of hydration in some patients was also one of the key areas that were discussed in the research. The responses highlighted the need for more effective ways of managing symptoms based on evidence. Further studies on better ways of symptoms management also emerged as a key way of improving the comfort of patients in palliative care. Communication was also among the crucial issues raised by the respondents

More than half of elderly people in geriatric wards due to lack of proper care (Beernaert et al, 2017). The comfort of this patient in most geriatric wards is also a key area of concern. Application of the Care Program for the Last Days of Life (CAREFuL) programme in hospitals in Belgium proved to lead to more comfort and care accorded to the patients than in the case of application of standard health care. The application of the CAREFuL program was recognized by the patients, their relatives and health professionals as a better way of taking care of patients in the dying phase. The application of better care for patients in geriatric wards relives the patients of much discomfort and their relatives have less distress (Davies, Waghorn, & Johnsen, 2017). The End-Of-Life in Dementia Comfort Assessment in Dying (CAD- EOLD) and the End-Of-Life in Dementia Symptoms Management (SM-EOLD) indicate the effectiveness of using an alternative program such as CAREFuL instead of the standard healthcare practice (Roeland et al, 2016).

Poor research on palliative care is a major reason why medical professionals have trouble taking optimum care of elderly patients (Kelley & Morrison, 2015). Fewer funds are located in the research on palliative care than it is the case with the research on cancer. The only alternative that medical professionals are left with when confronted by patients with a terminal illness is symptom management which may not be effective in all instances since the cause of the displayed signs may be totally unknown. Research also indicates that the priorities of the researchers are also aligned to other areas besides taking proper care of elderly patients (Mandawat, Heidenreich & Bhatt, 2017). The little knowledge that is available on taking proper care of these patients’ leads to high levels of discomfort for the patients which in turn causes a lot of stress for their relatives. The establishment of the PeolcPSP by James Lind Alliance Surveys is one of the notable initiatives aimed at drawing more attention to research on medical care (Garcia et al, 2016). Understanding the illness that many old people are projected to increase comfort for patients in palliative care.

Managing symptoms is widely applied in facilities that take care of terminally-ill elderly patients (Lotstein, Jonas & Kaye, 2018). Symptoms such as pain cause distress for the patients, their relatives, and medical professionals. Most of the care accorded to patients in palliative care is basically offsetting the prevailing causes of agitation of a patient at a particular moment and not a systematic treatment aimed at curing a known disease (Sullivan, 2017). The pain that patients go through in the process is a great source of discomfort in the dying moments and their relatives are affected psychologically too. Medical professionals may also be troubled by the fact that their efforts bear little fruits (Good, Richard, Syrmis, Jenkins-Marsh & Stephens, 2014). Clinical guidelines such as the National Institute for Health and Care Excellence (NICE) emphasize on boosting the levels of comfort of the patients by offsetting conditions such as pain and hydration and there is little mention of treating the patients (Chan, Yu, Leung, Chan, & Hui, 2016). Government policy also emphasizes on reducing the distress of patients and their relatives through the management of symptoms at the end-of-life periods. The ineffectiveness of the attempts to save the patients from pain and discomfort by managing their symptoms only causes the patients, their relatives, and clinicians a lot of distress.

The place from which patients receive end-of-life also determines their comfort and that of their relatives as well (Nielsen, Beermann, Carus, & Cook, 2017). According to a study conducted by PeolcPSP, many relatives and patients hold the belief that patients are accorded better care in non-palliative care since the attention of the medical professionals is undivided. The regulations of the interactions between the patients and their relatives are also minimal under private care than in palliative care. Most of the relatives of patients also believe that the medical professionals are more attentive to their concerns regarding the treatment of the patients (Berman, 2017). The high levels of concern among most relatives of patients make them prefer non-palliative professionals since they are considered to have more room for the intervention of the relatives (Reyes-Ortiz, Williams & Westphal, 2015). Changing the place of care from palliative to non-palliative facilities only relieves the relatives of their distress but the pain of the patients is not necessarily reduced. The limitation of this preference if the high cost of providing necessary care as it is in palliative care in the preferred care areas for the patients (Washington, Al-Kindi, Oliveira, & Robinson, 2017). The compromise of standard medical protocol in the alternative areas chosen by patients and their relatives is also a critical factor that has to be considered.

Primary versus Secondary Research

Hydration and nutrition are also key areas of concern for patients in palliative care as well as their relatives (Cheng et al, 2015). Enteral nutrition is lowly regarded by some patients and some relatives share the sentiments too. A research conducted by PeolcPSP indicates that the relatives of most patients under palliative care prefer to keep the patients out of the discomfort caused by thirst. Breathing difficulties and respiratory secretions are also among the issues that cause the relatives of patients to be concerned. The treatment of symptoms is, however, inefficient since the offsetting of conditions in only temporary and the bodies of the patients may be too weak or unresponsive to the remedies availed (Yang, Lin, Hsieh & Chang, 2015). Sedation remains to be the only remedy for terminal agitation and very little is done beside the administration of sedatives in the end-of-time periods. Enteral nutrition is also considered to be a violation of the autonomy of the patient in question despite the belief by their relatives that the patients should be granted their wishes at these end-of-life times. The comfort of patients is highly curtailed by professional requirements, for instance, the intake of water has to be through tubes but cases have arisen where relatives insist that the patients be allowed to take water orally in times of critical illness in a bid to boost their comfort (Choy, Burn, McLachlan, & Hall, 2017).

References

Berman, E. P. (2017). Creating University-Industry Research Centers. Princeton University Press. doi:10.23943/princeton/9780691147086.003.0006

Chan, H. Y., Yu, D. S., Leung, D. Y., Chan, A. W., & Hui, E. (2016). Quality of life and palliative care needs of elderly patients with advanced heart failure. Journal of geriatric cardiology: JGC, 13(5), 420.

Cheng, H. W. B., Li, C. W., Chan, K. Y., Au, H. Y., Chan, P. F., Sin, Y. C., ... & Sham, M. K. (2015). End-of-life characteristics and palliative care provision for elderly patients suffering from acute myeloid leukemia. Supportive Care in Cancer, 23(1), 111-116.

Choy, C., Burn, K., McLachlan, E., & Hall, E. (2017). P-170 Detecting suicidal thoughts in palliative care: when do patients voice these thoughts?

Davies, A., Waghorn, M., & Johnsen, S. (2017). O-6 A cluster randomized trial of clinically assisted hydration at the end of life.

Garcia, M. A., Balboni, T. A., Braunstein, S. E., Fogh, S. E., Anderson, W., Pantilat, S., ... & Hertan, L. M. (2016). Acute pain management in radiation oncology: Quality of care and the impact of an integrated palliative oncology service.

Good, P., Richard, R., Syrmis, W., Jenkins-Marsh, S., & Stephens, J. (2014). Medically assisted nutrition for adult palliative care patients. The Cochrane database of systematic reviews, (4), CD006274-CD006274.

Kelley, A. S., & Morrison, R. S. (2015). Palliative care for the seriously ill. New England Journal of Medicine, 373(8), 747-755.

Lotstein, D., Jonas, D., & Kaye, B. (2018). Management of Severe Perinatal Osteogenesis Imperfecta: A Perfect Role for Palliative Care.

Mandawat, A., Heidenreich, P. A., & Bhatt, D. L. (2017). Trends in Palliative Care Use in Elderly Men and Women With Severe Heart Failure in the United States—Reply. Jama cardiology, 2(3), 344-345.

Nielsen, R. E., Beermann, T., Carus, A., & Cook, M. E. (2017). MON-P102: Dietetic Counseling in a Nutrition Team Improves Nutritional Status for Patients with Upper Gastrointestinal Cancer During Palliative Chemotherapy. Clinical Nutrition, 36, S217.

Reyes-Ortiz, C. A., Williams, C., & Westphal, C. (2015). Comparison of early versus late palliative care consultation in end-of-life care for the hospitalized frail elderly patients. American Journal of Hospice and Palliative Medicine®, 32(5), 516-520.

Roeland, E. J., Triplett, D. P., Matsuno, R. K., Boero, I. J., Hwang, L., Yeung, H. N., ... & Murphy, J. D. (2016). Patterns of palliative care consultation among elderly patients with cancer. Journal of the National Comprehensive Cancer Network, 14(4), 439-445.

Sullivan, C. (2017). Diet and Nutrition in Palliative Care. Journal of Palliative Medicine, 20(7), 794-794.

Washington, J., Al-Kindi, S. G., Oliveira, G. H., & Robinson, M. R. (2017). Inpatient Palliative Care Utilization in Elderly Patients Admitted with Heart Failure in the United States. Journal of Cardiac Failure, 23(8), S118.

Yang, C. W., Lin, H. H., Hsieh, T. Y., & Chang, W. K. (2015). Palliative enteral feeding for patients with malignant esophageal obstruction: a retrospective study. BMC palliative care, 14(1), 58.