Search

Objectives Challenges inherent in the practice of continuous palliative sedation until death appear to be particularly pervasive in nursing homes. We aimed to develop a protocol to improve the quality of the practice in Belgian nursing homes. Methods The development of the protocol was based on the Medical Research Council Framework and made use of the findings of a systematic review of existing improvement initiatives and focus groups with 71 health care professionals [palliative care physicians, general practitioners (GPs), and nursing home staff] identifying perceived barriers to the use of continuous palliative sedation until death in nursing homes. The protocol was then reviewed and refined by another 70 health care professionals (palliative care physicians, geriatricians, GPs, and nursing home staff) through 10 expert panels. Results The final protocol was signed off by expert panels after 2 consultation rounds in which the remaining issues were ironed out. The protocol encompassed 7 sequential steps and is primarily focused on clarification of the medical and social situation, communication with all care providers involved and with the resident and/or relatives, the organization of care, the actual performance of continuous sedation, and the supporting of relatives and care providers during and after the procedure. Although consistent with existing guidelines, our protocol describes more comprehensively recommendations about coordination and collaboration practices in nursing homes as well as specific matters such as how to communicate with fellow residents and give them the opportunity to say goodbye in some way to the person who is dying. Conclusions and Implications This study succeeded in developing a practice protocol for continuous palliative sedation until death adapted to the specific context of nursing homes. Before implementing it, future research should focus on developing profound implementation strategies and on thoroughly evaluating its effectiveness.

ObjectiveTo identify strategies and interventions used to improve interprofessional collaboration and integration (IPCI) in primary care.DesignScoping reviewData sourcesSpecific Medical Subject Headings terms were used, and a search strategy was developed for PubMed and afterwards adapted to Medline, Eric and Web of Science.Study selectionIn the first stage of the selection, two researchers screened the article abstracts to select eligible papers. When decisions conflicted, three other researchers joined the decision-making process. The same strategy was used with full-text screening. Articles were included if they: (1) were in English, (2) described an intervention to improve IPCI in primary care involving at least two different healthcare disciplines, (3) originated from a high-income country, (4) were peer-reviewed and (5) were published between 2001 and 2020.Data extraction and synthesisFrom each paper, eligible data were extracted, and the selected papers were analysed inductively. Studying the main focus of the papers, researchers searched for common patterns in answering the research question and exposing research gaps. The identified themes were discussed and adjusted until a consensus was reached among all authors.ResultsThe literature search yielded a total of 1816 papers. After removing duplicates, screening titles and abstracts, and performing full-text readings, 34 papers were incorporated in this scoping review. The identified strategies and interventions were inductively categorised under five main themes: (1) Acceptance and team readiness towards collaboration, (2) acting as a team and not as an individual; (3) communication strategies and shared decision making, (4) coordination in primary care and (5) integration of caregivers and their skills and competences.ConclusionsWe identified a mix of strategies and interventions that can function as ‘building blocks’, for the development of a generic intervention to improve collaboration in different types of primary care settings and organisations.

Objective The impact of various psychosocial factors (sense of coherence, illness perception, patient enablement, self-efficacy, health literacy, personality) is not fully understood across a wide range of chronic diseases, and in particular in patients with multimorbidity. As such, this study assessed the key psychosocial factors associated with impaired health-related quality of life (HRQoL) in patients with one or more chronic diseases based on cross-sectional data collected in Flanders (Belgium). Methods Cross-sectional data on 544 chronically ill patients were analysed. Multiple linear regression models were built to analyze the key psychosocial factors associated with HRQoL (EQ-5D-5Lindex as dependent factor). Results Overall, the strongest independently associated factor with HRQoL was illness perceptions (β = −0.52, P < 0.001). In addition, sense of coherence (β = 0.14, P = < 0.05) was independently positively associated with HRQoL. Moreover, after stratification for multimorbidity, the negative association of illness perceptions with HRQoL was stronger when multimorbidity is present compared to when it is absent (β = −0.62, P < 0.001 vs β = −0.38, P < 0.001). Conclusions This study revealed interesting associations of the modifiable psychosocial factors of illness perceptions and sense of coherence with HRQoL in a population of chronically ill persons. Given that the burden of chronic diseases will rise in the next decades, designing and implementing interventions that enhance these psychosocial abilities of patients, especially illness perceptions in multimorbid patients, is needed in order to reduce the burden of chronic diseases in terms of impaired HRQoL.

Background: There is recognition that older people with incurable conditions should have access to specialist palliative care services. However, it remains unclear which activities and outcomes these services entail for older people in primary care and to which patients they are provided. Aim: The aim of this review was to identify the criteria for referral to specialist services; who provides specialist palliative care; through which activities and with which frequency; which outcomes are reported; and which suggestions are made to improve services. Design: Systematic review of the literature and narrative synthesis. Quality appraisal and selection of studies were performed independently by two researchers. Participant characteristics, intervention features, outcome data and suggestions for improvement were retrieved. Data sources: Embase, Medline, Web of Science, Cochrane, Google Scholar, PsycINFO and CINAHL EBSCO databases (until June 2019). Results: Ten eligible articles, three qualitative, three quantitative, three mixed-method and one narrative review, were identified. Referral criteria were mainly based on patient characteristics such as diagnosis. The specialist services involved a variety of activities and outcomes and descriptions were often lacking. Services could be improved regarding the information flow between healthcare professionals, greater in-depth palliative care knowledge for case managers and social workers, identification of a key worker and support for family carers. Conclusion: The limited evidence available shows areas for improvement of the quality of and access to specialist services for older people, such as support for family carers. In addition, this review underscores the need for comprehensive reporting of interventions and the use of consensus-based outcome measures.

Aims and objectives To explore how community nurses experience the collaboration with general practitioners and specialist palliative home care team nurses in palliative home care and the perceived factors influencing this collaboration. Background The complexity of, and the demand for, palliative home care is increasing. Primary palliative care is provided by community nurses and general practitioners, often in collaboration with palliative home care team nurses. Although these professionals may each individually be part of a fixed team, a new temporary team is often composed for every new palliative patient. These membership changes, referred to as team membership fluidity, challenge professionals to work effectively. Design and methods A qualitative research design, using semi-structured interviews with community nurses. Participant selection happened through regional palliative care networks in Belgium. The network's palliative home care team nurses selected community nurses with whom they recently collaborated. Twenty interviews were conducted. A constant comparative analysis approach was used. Consolidated criteria for reporting qualitative research guidelines were followed. Results Formal interprofessional team meetings were not common practice. The other's approachability and knowing each other positively influenced the collaboration. Time constraints, the general practitioners' lack of expertise, communication style, hierarchy perception and income dependency negatively influenced the collaboration with general practitioners and determined palliative home care team nurses' involvement. The coping strategies of community nurses balanced between a behaviour focused to the patient and to the professional relationship. Specialist palliative home care team nurses were relied upon for their expertise but also to mediate when community nurses disagreed with general practitioners. Conclusion Community nurses showed to be highly adaptable within the fluid team. Strikingly, dynamics described in the doctor-nurse game 50 years ago are still present today and affect the interprofessional communication. Interprofessional education interventions can contribute to improved interprofessional collaboration. Relevance to clinical practice The study findings uncovered critical knowledge gaps in interprofessional collaboration in palliative home care. Insights are relevant for and related to professional well-being and workplace learning.

Background: Extensive debate surrounds the practice of continuous sedation until death within end-of-life care. Aim: To provide insight into existing initiatives to support the practice of continuous sedation until death and assess their feasibility and effectiveness. Design: Systematic review and narrative synthesis, registered on PROSPERO (CRD42020149630). Data sources: Records were searched through MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science from inception to April 16 2020. Peer-reviewed studies reporting original data on initiatives to support the practice of continuous sedation were included for review. Results: Twenty-one studies met the criteria and were included. Initiatives were focused on assessment tools of consciousness and discomfort (9), the use of guidelines and protocols (8), and expert consultation (3). All initiatives were reported as useful, acceptable, and feasible. Studies on the use of monitoring devices showed that a small proportion of patients were found to be awake, despite the patient being unresponsive according to the observer-based sedation scales. However, the wide range of values of these monitoring devices for comfortable and adequately sedated patients seems to hamper its overall implementation in daily clinical practice. Physicians reported changes in practice conform to guideline recommendations but the shift was modest at best. Expert consultation was regarded as supportive when sufficient expertise is lacking and helpful in avoiding possibly unnecessary sedations. Conclusions: The reviewed initiatives may contribute to improvement of continuous sedation until death, though their evidence base is rather limited. More insight is needed into their feasibility, preconditions for effective implementation and impact in actual practice.

ispartof: Patient Education And Counseling vol:104 issue:3 pages:464-466 ispartof: location:Ireland status: published

IntroductionThere is limited evidence regarding the effectiveness of timely integration of short-term specialised palliative care services for older people in primary care. Using a Theory of Change approach, we developed such an intervention, the Frailty+ intervention. We present the protocol of a pilot randomised controlled trial (RCT) with a process evaluation that aims to assess the feasibility and preliminary effectiveness of the Frailty+ intervention.Methods and analysisWe will conduct a pilot RCT in Flanders, Belgium. Frail older people who are discharged to home from hospital will be identified and recruited. Seventy-six will be randomly assigned either to the control group (standard care) or the intervention group (Frailty+ intervention alongside standard care). Data will be collected from patients and family carers. At the core of the Frailty+ intervention is the provision of timely short-term specialised palliative care facilitated by a nurse from the specialised palliative home care service over a period of 8 weeks. We will assess feasibility in terms of recruitment, randomisation, acceptability of the intervention, retention in the programme and data completion. The primary outcome for assessing preliminary effectiveness is a mean score across five key symptoms that are amenable to change (ie, breathlessness, pain, anxiety, constipation, fatigue), measured at baseline and 8 weeks post-baseline. The process evaluation will be conducted in the intervention group only, with measurements at 8–11 weeks post-baseline to evaluate implementation, mechanisms of change and contextual factors.Ethics and disseminationThe study has been approved by the ethics committee of University Hospital Ghent. Results will be used to inform the design of a full-scale RCT and will be published in a peer-reviewed, open access journal.Trial registration numberISRCTN39282347; Pre-results.

IntroductionNon-communicable diseases (NCDs) are associated with lower health-related quality of life (HRQoL). However, knowledge about those diseases and predictors with a greater impact on patients’ HRQoL as well as knowledge on the complex relationship between HRQoL and comorbidities is lacking. The aim of this study is to assess the impact of NCDs on patients’ HRQoL, with a focus on multimorbidity and socioeconomic status.Methods and analysisA primary care-based cross-sectional study is conducted in Flanders (Belgium). Study participants (≥18 years) are medically diagnosed with at least one of the following diseases: cardiometabolic disorders, mental disorders and musculoskeletal disorders. A minimum of 50 general practitioners will participate to recruit participants (convenient sample) and a total of 531 patients will be enrolled (voluntary response sample). Each participant will complete a paper-based questionnaire to gather research outcomes. Statistical analyses will be performed using multiple linear regression models with HRQoL as main outcome parameter, adjusted for possible confounders. This study will generate new evidence on the key predictors of HRQoL in patients with NCDs, and particularly provide new insights in multimorbidity to improve the quality of care in primary care, to support patients’ self-management and to allocate resources more effectively.Ethics and disseminationThe study has been approved by the Ethical Committee of Ghent University Hospital, Ghent, Belgium (reference number: B670201939629) prior to the beginning of the recruitment. Study results will be disseminated through peer-reviewed publications and conference presentations.

OBJECTIVE: To investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it. METHODS: We coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters. RESULTS: We identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor. CONCLUSION: In IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction. PRACTICE IMPLICATIONS: Doctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other's communicative goals. epub ahead of print ispartof: Patient Education and Counseling vol:103 issue:3 pages:1-9 ispartof: location:Ireland status: Published online

Context Although early integrated palliative home care (PHC) is believed to be beneficial for patients with chronic obstructive pulmonary disease (COPD), trials testing this hypothesis are rare and show inconclusive results. Objectives To test feasibility, acceptability, and preliminary effectiveness of early integrated PHC for end-stage COPD. Methods Testing a six-month early integrated PHC pilot randomized controlled trial given by palliative home care nurses (PHCNs) for end-stage COPD with five components: 1) preinclusion COPD support training for PHCNs; 2) monthly PHC visits; 3) leaflets on coping mechanisms; 4) a protocol on symptom management and support, a care plan and an action plan; and 5) integration of PHC and usual care through reporting and communication mechanisms. Patient-reported outcomes were assessed six times weekly. Participants and health care professionals involved were interviewed. Results Of 70 eligible patients, 39 (56%) participated (20:19 intervention vs control group) and 64% completed the trial. A patient received on average 3.4 PHC visits, mainly for disease insight, symptom management, and care planning. Nurses distributed all reports but hardly connected with health professionals except general practitioners (GPs); eight of 10 interviewed patients referred to the psychosocial support, breathing exercises, and care decisions as helpful. Some GPs criticized PHC being given too early, but pulmonologists and PHCNs did not. Effectiveness analysis showed no overall intervention effect for the outcomes, but between baseline and week 24, fewer hospitalizations in the control group (P = 0.03) and a trend of higher perceived quality of care in the intervention group (P = 0.06) were found. A clinically relevant difference was observed at week 24 for health-related quality of life in favor of the control group. Conclusion Our intervention on early integrated PHC for end-stage COPD is feasible and accepted but did not yield the anticipated preliminary effectiveness. Before moving to a Phase III trial, enhanced coordination of care, more GP involvement, more intensive training for PHCNs in COPD support, and revision of the trial design, for example, of targeted outcomes in line with individual patient goals and care preferences should be done.

Background To be able to practice evidence-based medicine (EBM) when making decisions for individual patients, it is important to learn how to combine the best available evidence with the patient’s preferences and the physician’s clinical expertise. In general practice training, these skills can be learned at the workplace using learning conversations: meetings between the supervising general practitioner (GP) and GP trainee to discuss medical practice, selected topics or professional performance. This study aimed to give insight into the perceptions of GP trainees on their EBM learning processes during learning conversations. Methods We held semi-structured video-stimulated elicitation interviews (n = 22) with GP trainees affiliated to GP training institutes in the Netherlands and Belgium. GP trainees were shown fragments of their learning conversations, enabling reflection during the interview. Taking an inductive approach, interview recordings were transcribed verbatim and analysed with NVivo software. Results GP trainees perceived learning conversations as useful for learning and discussing EBM. Multiple EBM learning activities were identified, such as discussing evidence together, relating evidence to cases in daily practice and discussing the supervisor’s experience and the specific local context in the light of what the evidence recommends. However, for learning to occur, trainees need and expect specific behaviour, both from their supervisors and themselves. Supervisors should supply well-substantiated answers that are applicable in practice and give the trainee confirmation. In turn, the trainee needs to prepare well in order to ask focused, in-depth questions. A safe space allowing equal and open discussion between trainee and supervisor is perceived as an essential context for optimal EBM learning. Conclusions Our findings show that trainees find learning conversations useful for EBM learning in general practice. To bring EBM learning to its full potential, attention should be paid to optimising the behavioural and contextual factors found relevant to enhancing EBM learning.

Background Evidence-based medicine (EBM) in general practice involves applying a complex combination of best-available evidence, the patient’s preferences and the general practitioner’s (GP) clinical expertise in decision-making. GPs and GP trainees learn how to apply EBM informally by observing each other’s consultations, as well as through more deliberative forms of workplace-based learning. This study aims to gain insight into workplace-based EBM learning by investigating the extent to which GP supervisors and trainees recognise each other’s EBM behaviour through observation, and by identifying aspects that influence their recognition. Methods We conducted a qualitative multicentre study based on video-stimulated recall interviews (VSI) of paired GP supervisors and GP trainees affiliated with GP training institutes in Belgium and the Netherlands. The GP pairs (n = 22) were shown fragments of their own and their partner’s consultations and were asked to elucidate their own EBM considerations and the ones they recognised in their partner’s actions. The interview recordings were transcribed verbatim and analysed with NVivo. By comparing pairs who recognised each other’s considerations well with those who did not, we developed a model describing the aspects that influence the observer’s recognition of an actor’s EBM behaviour. Results Overall, there was moderate similarity between an actor’s EBM behaviour and the observer’s recognition of it. Aspects that negatively influence recognition are often observer-related. Observers tend to be judgemental, give unsolicited comments on how they would act themselves and are more concerned with the trainee-supervisor relationship than objective observation. There was less recognition when actors used implicit reasoning, such as mindlines (internalised, collectively reinforced tacit guidelines). Pair-related aspects also played a role: previous discussion of a specific topic or EBM decision-making generally enhanced recognition. Consultation-specific aspects played only a marginal role. Conclusions GP trainees and supervisors do not fully recognise EBM behaviour through observing each other’s consultations. To improve recognition of EBM behaviour and thus benefit from informal observational learning, observers need to be aware of automatic judgements that they make. Creating explicit learning moments in which EBM decision-making is discussed, can improve shared knowledge and can also be useful to unveil tacit knowledge derived from mindlines.

Background: Despite the risk for developing mental disorders, the majority of advanced cancer patients’ family caregivers undergo a resilient process throughout the caregiving period. Research on resilience in caregivers of advanced cancer patients is scarce and further hindered by the lack of a univocal definition and a theoretical framework. Objectives: To provide clarity on the concept of resilience by proposing an integrative view that can support health care professionals and researchers in conducting and interpreting research on resilience. Methods: The review process was inspired by the hermeneutic methodology: a cyclic review process, consisting of repeated searching and analysing until data saturation is reached and focused on achieving a deeper understanding of ill-defined concepts. The definitions from eighteen reviews on resilience and the theoretical frameworks from eight concept analyses were analysed. The composing elements of resilience were listed and compared. Results: The American Psychological Association’s definition of resilience and Bonanno’s theoretical framework are suggested to guide further research on resilience. Moreover, four knowledge gaps were uncovered: (1) How do resilience resources interact? (2) What are the key predictors for a resilient trajectory? (3) How do the resilient trajectories evolve across the caregiving period? And (4) how does the patient’s nearing death influence the caregiver’s resilience? Conclusion: To address flaws in conceptualization and the resulting gaps in knowledge, we suggest a definition and a theoretical framework that are suited to allow heterogeneity in the field, but enables the development of sound interventions, as well as facilitate the interpretation of intervention effectiveness. ispartof: European Journal Of General Practice vol:26 issue:1 pages:79-85 ispartof: location:England status: published

IntroductionEffective doctor–patient communication in oncology settings can be challenging due to the complexity of the cancer disease trajectory. The challenges can become greater when doctors and patients do not share a common language and need to rely on language mediators. The aim of this study is to provide evidence-based recommendations for healthcare professionals, patients and language mediators on how to interact with each other during language-mediated consultations in oncology settings.Methods and analysisA systematic review of the literature on communication problems in monolingual and multilingual oncology settings will be conducted. Thirty language-mediated consultations with Turkish-speaking or Arabic-speaking cancer patients, language mediators and Dutch-speaking oncologists/haematologists will be video-recorded in three urban hospitals in Flanders, Belgium. All participants will be interviewed immediately after the consultation and 2 weeks after it by means of video-stimulated recall. Multimodal interaction analysis will be combined with qualitative content analysis to allow for the identification of communication practices when communication problems occur.Ethics and disseminationThe study has been approved by the following ethics committees: Ghent University Hospital, Antwerp University Hospital, Antwerp Hospitals Network (ZNA). Results will be published via (inter)national peer-reviewed journals and the findings of the study will be communicated using a comprehensive dissemination strategy aimed at healthcare professionals, patients and language mediators.

Cancer and nutrition-related problems are extremely distressing events and disturb functioning and daily life. It is recognized that the effects of stressors challenging well-being are mediated by the meaning attached to these stressors. As nutrition-related problems are often being experienced within couples, it is also important to gain understanding of a partner's interpretation of complaints and whether it coincides with that of the patient.To explore the meaning attached to nutrition-related problems, a qualitative approach was followed. Seven couples, each composed of a patient with cancer and his/her cohabiting life partner, participated. Data were collected through in-depth interviews and analyzed by an interpretative phenomenological approach.Nutrition-related problems among patients with advanced cancer are mostly perceived as destroying health and leading to loss of physical, psychological, and social health symbols. Because the meaning patients and their partners attach to nutrition-related problems is individual and dynamic, it is necessary to devote special attention to the issues on different occasions.The study findings can assist nurses and other professional caregivers in providing psychological support for couples confronted with nutrition-related problems in advanced cancer. It is important to take into account the meaning patients and partners attach to these nutrition-related problems.

Lynn conceptualized end-of-life (EoL) care for patients with advanced chronic-progressive illnesses as a combination of life-preserving/palliative care, the palliative aspect gradually becoming the main focus as death approaches. We checked this concept by exploring the advanced-terminal illness trajectories of 50 patients. Strategies heralding active therapy exhaustion were the catalyst for a participant’s awareness of terminality, but were not a decisive factor in the divergent EoL care pathways we detected. The terms life-preserving and palliative do not adequately capture EoL care pathways due to their conceptual ambiguity. Conversely, the concept of EoL care encompassing three palliative care modalities ( life-prolonging palliative therapy, restorative palliative care, and symptom-oriented [only] palliative care), each harboring a different blend of life-preserving and symptom-comforting aspects, proved adequate. These modalities could run serially, oscillatorily, or parallelly, explaining the divergent EoL care pathways. We suggest an adjustment of the model of Lynn and reconsider the traditional palliative care concept.

Construct: This study presents a tool that can facilitate a conversation about students' and supervisors' expectations concerning responsibilities during workplace learning. Background: It is often unclear who is responsible for facilitating learning opportunities in the workplace. In order to increase learning opportunities, it is important that expectations are discussed and alignment is reached between the student's and supervisor's expectations. This study collected and interpreted validity evidence for a tool that aims to provoke such a conversation. Approach: Three types of validity evidence were collected: response process, content, and consequences evidence. Educational leaders, medical teachers, and students of four medical schools were involved. The data collection consisted of cognitive interviews, a modified Delphi approach (with three rounds of inquiry), completed tools, and narrative comments. Findings: This study showed that the expectations of most students and supervisors were not initially aligned. The conversation, for which the tool aims to be a catalyst, facilitated better alignment of expectations about responsibilities during workplace learning. Moreover, the students' perceived degree of consensus and satisfaction after the conversation were very high. Conclusions: This study underlined the relevance and usefulness of a tool that facilitates conversation about expectations regarding responsibilities, potentially enhancing learning opportunities at the workplace. ispartof: Teaching And Learning In Medicine vol:32 issue:3 pages:282-293 ispartof: location:United States status: published

Background General practice is an optimal setting for ensuring timely initiation of ACP discussions. A multi-component ACP intervention developed for the general practice setting, aimed at patients with chronic life-limiting illnesses and their general practitioner, has been pilot tested. The aim of this study is to evaluate the effectiveness of this intervention and to evaluate its implementation by means of a process evaluation. Methods/Design Using a cluster-randomized controlled trial (RCT) (randomization at the practitioner level, n=53 practitioners per condition, n=133 patients per condition), we will compare the structured ACP communication intervention to usual care, employing baseline measures (T0), and follow-up at 6 months (T1) and 12 months post-baseline (T2). Primary endpoints are quality of communication about end-of-life care and concordance between patients’ preferences and received care at the end of life (as reported by the family caregiver if the patient died). Other patient or caregiver-reported outcomes include health-related quality of life, anxiety and depression, quality of end-of-life care, and quality of death and dying. Following the RE-AIM framework, structured diaries for trainers and general practitioners, as well as qualitative interviews with general practitioners, patients and family caregivers are among the measures used for the process evaluation. Discussion After this Phase III RCT, we will be able to present a well-tested and evaluated ACP intervention that can be implemented in general practice. The results of the process evaluation will provide insight needed to allow adaptation of the intervention for a greater variety of national and international contexts.

Early integration of palliative home care (PHC) might positively affect people with chronic obstructive pulmonary disease (COPD). However, PHC as a holistic approach is not well integrated in clinical practice at the end-stage COPD. General practitioners (GPs) and community nurses (CNs) are highly involved in primary and home care and could provide valuable perspectives about barriers to and facilitators for early integrated PHC in end-stage COPD. Three focus groups were organised with GPs (n = 28) and four with CNs (n = 28), transcribed verbatim and comparatively analysed. Barriers were related to the unpredictability of COPD, a lack of disease insight and resistance towards care of the patient, lack of cooperation and experience with PHC for professional caregivers, lack of education about early integrated PHC, insufficient continuity of care from hospital to home, and lack of communication about PHC between professional caregivers and with end-stage COPD patients. Facilitators were the use of trigger moments for early integrating PHC, such as after a hospital admission or when an end-stage COPD patient becomes oxygen-dependent or housebound, positive attitudes towards PHC in informal caregivers, more focus on early integration of PHC in professional caregivers’ education, implementing advance care planning in healthcare and PHC systems, and enhancing communication about care and PHC. The results provide insights for clinical practice and the development of key components for successful practice in a phase 0–2 Early Integration of PHC for end-stage COPD (EPIC) trial, such as improving care integration, patients’ disease insight and training PHC nurses in care for end-stage COPD., Chronic lung disease: Improving palliative care Research in Belgium provides insights into the possible implementation of early palliative care (PC) for patients with chronic obstructive pulmonary disease (COPD). While many sufferers of end-stage COPD would benefit emotionally and physically from palliative home care in their final months, many only receive PC in their last few days. Charlotte Scheerens at End-of-life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB) and co-workers at Ghent University and Vrije Universiteit Brussel (VUB) conducted focus group discussions with 28 general practitioners and 28 community nurses to establish the main barriers to and facilitators for palliative home care implementation for end-stage COPD. Barriers included the unpredictability of the disease, lack of patient understanding of COPD, and complex communication issues between staff across primary care, hospitals and community settings. Identifying ‘triggers’ to implement PC—oxygen dependence, for example—and improving communication and understanding of COPD at all levels could facilitate early integration of palliative home care (PHC).

In response to calls in the literature for more collaborative practice in interpreter training, this paper describes the design, implementation and part of the evaluation of an innovative joint training intervention for interpreting students (Master’s level) and 3rd- and 4th-year medical students at Ghent University. In order to assess the development of the students’ knowledge and skills, we employed self-efficacy questionnaires; the training intervention was evaluated in a debriefing session with trainers from both fields. A development in skills that involve direct interaction with the primary participants and address specific communicative goals was noted. Our initial evaluation suggests that interprofessional education and collaborative practice in interpreter training can create the conditions for interpreting students to develop a more insightful and reflective approach to their interpreting practice.

Background: Research about advance care planning (ACP) has often targeted those with serious illness and limited prognosis, thereby not addressing the preferences of healthy adults or adults with a stable condition. Aims: (i) To describe to what extent patients aged 50 and older who are relatively stable or in good health are thinking about the end of life (EOL) and willing to discuss this with their family physician (FP) and (ii) to explore whether patients and FPs indicate the same topics as triggers for ACP discussions in family practice. Methods: A cross-sectional study was conducted in a diverse sample of 289 patients aged >= 50 years in family practice in Flanders, Belgium. Subsequently, semi-structured interviews were conducted with patients (n = 5) and FPs (n = 5) to explore their preferences and views on ACP in family practice. Results: The majority (69.8%) of patients had thought about the EOL and would appreciate it if their FP would initiate a conversation about this (75.9%). The qualitative interviews revealed that when thinking about the EOL, a number of themes captured the thoughts of people according to both patients and FPs: (i) becoming care dependent, (ii) physical and mental deterioration, (iii) dying alone and (iv) having paperwork in order. However, on the basis of patients' ideas and FPs' experiences in practice, a difference was noticed between them when it comes to identifying the themes as triggers for initiating ACP discussions. Conclusion: Although patients are willing to discuss the EOL with their FPs, patients and FPs identified different themes as triggers to initiate discussions about the EOL. The variation in triggers could lead to missed opportunities to engage in ACP in a timely manner.

Polypharmacy results in adverse drug interactions, high pill burden, and medication costs. Stopping or diminishing potentially inappropriate medication (PIM), is complex . Data on the use of PIM in a primary care context are scarce and deprescribing barriers for general practitioners (GP) are underexplored.Describing the use of PIM in primary care at the end of life, and exploring the barriers for GPs to deprescribe.Retrospective chart review of 210 consecutive patients referred to a palliative home care service and semi-structured interviews with 11 GPs. Percentages were calculated on medication use, linear regression was done to evaluate the effect of diagnosis on PIM use. Thematic analysis was used to analyze the interviews.In total 83 % of patients took at least one PIM. The proportion that continued taking PIMs at the time of referral, one week prior to death and at the day of dying: varies between 6% and 45% according to drug category. Linear regression showed a statistical significant (p 0.001) higher number of PIM use with non-cancer patients (mean 3,1-SD 1,5) than with cancer patients (mean 1,6-SD 1,6). Participants reported being aware of the PIM use, making efforts to deprescribe. Main issues GPs are taking into account are medical, communicative, and collaborative in nature.This study confirms the high level of PIM use in primary care at the end of life. The views of GPs inspire support strategies for deprescribing focusing on shared decision-making with patients and on interprofessional collaboration.

The aim of this study is to test the feasibility of a tool to objectify the functioning of healthcare teams operating in the complexity zone, and to evaluate its usefulness in identifying areas for team quality improvement.We distributed The Complex Adaptive Leadership (CAL™) Organisational Capability Questionnaire (OCQ) to all members of one palliative care team (n=15) and to palliative care physicians in Flanders, Belgium (n=15). Group discussions were held on feasibility aspects and on the low scoring topics. Data was analysed calculating descriptive statistics (sum score, mean and standard deviation). The one sample T-Test was used to detect differences within each group.Both groups of participants reached mean scores ranging from good to excellent. The one sample T test showed statistically significant differences between participants' sum scores within each group (p0,001). Group discussion led to suggestions for quality improvement e.g. enhanced feedback strategies between team members.The questionnaire used in our study shows to be a feasible and useful instrument for the evaluation of the palliative care teams' day-to-day operations and to identify areas for quality improvement.The CAL™OCQ is a promising instrument to evaluate any healthcare team functioning. A group discussion on the questionnaire scores can serve as a starting point to identify targets for quality improvement initiatives.

Background: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients’ care. General practitioners (GPs) are invited to join, but their participation is minimal. Objectives: Aim of this study is to explore participating GPs’ perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings. Methods: In May to June 2014, semi-structured interviews (n = 16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles. Results: Attendance of an MDT meeting is perceived as part of the GP’s work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP’s perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP’s intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics. Conclusion: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.

High-quality doctor-patient communication in end-of-life care results in better quality of life for patients. In linguistically and culturally diverse societies, language discordant consultations become daily practice, leading to difficulties in eliciting patient preferences toward end-of-life care. Although family members invariably act as informal interpreters, this may cause some ethical dilemmas. We present a case of a palliative patient whose son acted as an interpreter. This case generated a triple- layered ethical dilemma: (i) how to safeguard patient autonomy against paternalistic interventions by family members, (ii) how to respect the relational context in which patient autonomy can be realized, and (iii) how to respect the ethno-cultural values of the patient and his family. These issues are being discussed and reflected upon within the framework shared decision making involving informal- and professional interpreters. The complementary use of professional interpreters next to family members acting as informal interpreters is recommended.

Victims of disaster suffer, not only at the very moment of the disaster, but also years after the disaster has taken place, they are still in an emotional journey. While many moral perspectives focus on the moment of the disaster itself, a lot of work is to be done years after the disaster. How do people go through their suffering and how can we take care of them? Research on human suffering after a major catastrophe, using an ethics of care perspective, is scarce. People suffering from disasters are often called to be in distress and their emotional difficulties ‘medicalised’. This brings them often into a situation of long term use of medication, and one can wonder if medication is of help to them in the long run. In our paper, we will explore another moral perspective, focusing on the importance of the victims’ narrative and their lived experiences. We will use Paul Ricoeur’s phenomenological reflections from ‘Suffering is not the same as pain’ for conceptualizing human suffering and how to apply it to victims of disaster. Ricoeur suggests that suffering is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Above all, the perspective of care and listening could offer an opportunity to reconcile people from their loss and suffering.

Inter-professional education (IPE) can support professionals in developing their ability to work collaboratively. This position paper from the European Forum for Primary Care considers the design and implementation of IPE within primary care. This paper is based on workshops and is an evidence review of good practice. Enablers of IPE programmes are involving patients in the design and delivery, providing a holistic focus, focussing on practical actions, deploying multi-modal learning formats and activities, including more than two professions, evaluating formative and summative aspects, and encouraging team-based working. Guidance for the successful implementation of IPE is set out with examples from qualifying and continuing professional development programmes.

COPD patients often use many medical resources, such as hospital admissions and medical imaging, inappropriately close to death. Palliative home care (PHC) could beneficially affect this. The aim was to study the effect of use and timing of PHC on medical resource use and costs in the last 30 days before death (DBD) for COPD.We performed a retrospective study of all Belgian decedents in 2010–2015 with COPD and a primary cause of death being COPD or cardiovascular diseases. Odds ratios for medical resources were calculated between using and four PHC timing categories (>360, 360–181, 180–91 and 90–31 DBD) versus not using. Confounders were socio-demographic, care intensity and disease severity variables.Of the 58 527 decedents with COPD, 644 (1.1%) patients received PHC earlier than 30 DBD. Using PHC (versus not using) decreased the odds ratio for hospitalisation (0.35), intensive care unit admission (0.16), specialist contacts (0.58), invasive ventilation (0.13), medical imaging including chest radiograph (0.34), sedatives (0.48) and hospital death (0.14). It increased the odds ratio for home care (3.27), general practitioner contact (4.65), palliative care unit admission (2.61), noninvasive ventilation (2.65), gastric tube (2.15), oxygen (2.22) and opioids (4.04) (pHealth policy and services should focus on increasing PHC access, while research should further explore early PHC initiation for COPD.

Objective To identify the ways in which physicians, patients and interpreters express emotions, react to emotional expressions and/or coordinate the emotional interaction in interpreter-mediated consultations (IMCs). Methods We systematically searched four databases and screened 10 307 articles. The following inclusion criteria were applied: 1) participants are patients with limited proficiency in the host language, physicians and professional interpreters, 2) analysis of patient-physician-interpreter interaction, 3) focus on emotions, 4) in vivo spoken language interpretation, and 5) authentic primary data. Results The results of 7 included studies suggest that physicians, patients and interpreters work together and verbally and paraverbally contribute to the co-construction of emotional communication (EC) in IMCs. However, a decrease in EC might still compromise the patient’s quality of care in IMCs. Conclusion There is a dearth of scientific evidence of EC as an interactional process between participants in IMCs. More research on under investigated modes of communication and emotions is needed to advance our understanding. For now, EC seems to be subject to the successful interaction between participants in IMCs. Practice implications Evidence-based curricula of interprofessional education between physicians and interpreters on EC in IMCs could be beneficial to the effective co-construction of EC in IMCS. ispartof: Patient Education and Counseling vol:103 issue:1 pages:33-43 ispartof: location:Ireland status: published

Background: COPD patients often use extensive medical resources, e.g. frequent hospitalisations, when they are close to death. Palliative home care (PHC) could affect end-of-life medical resource use. However, population studies studying this possible effect for COPD are lacking. Aim: To study the effect of use and timing of PHC on medical resource use in the last 30 days before death (DBD) for COPD. Methods: Retrospective study of all Belgian decedents in 2010-2015 who died with COPD. Odds ratios (OR) for medical resources in the last 30 DBD were calculated between using versus not using PHC, and between four PHC timing categories (>360; 360-181; 180-91; 90-31 DBD) versus not using PHC. Confounders were socio-demographic, care intensity and disease severity variables. Results: Of the 58,527 decedents with COPD, 644 patients (1.1%) received PHC before 30 DBD. Using PHC (versus not using) decreased the OR for hospitalisation (0.35), intensive care unit admission (0.16), specialist contacts (0.58), invasive ventilation (IV) (0.13), medical imaging including chest radiograph (0.34), sedatives (0.48) and hospital death (0.14). It increased the OR for home care (3.27), general practitioner contact (4.65), palliative care unit admission (2.61), non-IV (2.65), gastric tube (2.15), oxygen (2.22), opioids (4.04) and morphine (5.29) (p 360 DBD (p

Interprofessional education and collaborative practice are gradually gaining importance in the context of growing healthcare complexity. The readiness for interprofessional learning scale (RIPLS) is a well-known scale that can identify attitudinal barriers and variance across professions, which may affect educational interventions.This study aims to translate the English RIPLS into Dutch and to test its reliability and validity.The scale was translated and back-translated by two pairs of people independently and tested for feasibility and comprehensibility. The translated scale was used with 219 general practitioners, 238 community nurses, and 53 palliative home-care nurses. Exploratory factor analysis was used to assess construct validity. Confirmatory factor analysis was done to generate a fit model. Cronbach's alpha was computed to evaluate internal consistency. Regression analysis was used to evaluate the effect of the RIPLS score on the level of learning through collaboration and to gauge the influence of the participants' gender, age, previous palliative care education, type of practice and years in practice.Confirmatory and exploratory factor analysis confirms the factor structure of the original version. The Dutch version shows good reliability (overall Cronbach's alpha: 0.88; intraclass correlation coefficient after test-retest: 0.718 (95%CI: 0.499-0.852). The RIPLS score correlates with the amount of workplace learning during collaboration (discriminant validity: P 0.001).The Dutch translation of the RIPLS is now ready for comparative studies.

Objectives workshops and specialized training programs are often inaccessible for speech and language pathologists (SLPs) based in resource-limited countries given the lack of supply, the long travel distances and the excessive participation fees. To stimulate life-long learning opportunities for all, this study described and measured the effect of a free, two-day cleft care workshop for SLPs in Uganda. The workshop included different topics related to the assessment and treatment of children with a cleft of the palate with or without a cleft of the lip (CP ± L). Methods The participants who presented during the two-day course were asked to complete a pre- and post-workshop questionnaire to evaluate their satisfaction. The pre-workshop form also included some questions concerning cleft care in Uganda. Both the pre- and post-workshop forms included three visual analogue scales to investigate the evolution of the participants' estimation of their knowledge regarding speech in patients with a CP ± L and to assess the changes in their self-confidence in the diagnosis and treatment of this population. Results seventeen SLPs completed the pre- and post-workshop questionnaires. In general, the participants were highly satisfied with the different themes covered in the program. After the training course, the participants rated their general knowledge about CP ± L and their self-confidence in the diagnosis and treatment of children with a CP ± L significantly higher than before the workshop. Conclusion the vast majority of the SLPs reported that cleft care was not easily accessible in Uganda. The most commonly reported obstacle for cleft care was a lack of knowledge about this matter in the SLPs themselves highlighting the importance of the organization of additional education opportunities. The participants reported a significantly higher level of self-confidence in diagnosing and treating children with a CP ± L after the workshop. The content of this workshop can form the basis for future learning opportunities for SLPs based in resource-limited countries.

BackgroundFamily caregivers of advanced cancer patients are at risk for developing mental disorders. Despite this risk, the majority seem to adapt well, and throughout the caregiving period, their trajectory is characterised by healthy functioning. However, GPs struggle with making timely assessments of caregivers at risk for mental dysfunction, since they often fail to seek medical help for themselves and the appropriate research about resilience in cancer caregivers is scarce. Moreover, research is hampered by the lack of a universal definition or theoretical framework.AimTo propose a comprehensive definition and framework for further research in family caregiving for advanced cancer patients.MethodInspired by the hermeneutic methodology, reviews and concept analyses on resilience following a potentially traumatic event were searched and analysed. Conforming to the hermeneutic methodology, article collection from PubMed, EMBASE, CINAHL, and PsycInfo was followed by analysis and was stopped when saturation was reached. Elements consistently arising from the definitions of resilience were listed and the theoretical frameworks were compared.ResultsThe APA definition: ‘resilience is the process of adapting well in the face of adversity, trauma or threats’ and Bonanno’s framework ‘temporal elements of resilience’ are proposed.ConclusionThere is a need for studies on resilience in caregivers of advanced cancer patients. Resilience is context-dependent, hence, study results cannot be transferred as such from one clinical situation to another. Furthermore, conceptual ambiguities hinder the interpretation and comparison of study results. For further research on resilience in caregivers of advanced cancer patients, we suggest the APA definition of resilience and Bonanno’s framework.

Background Descriptions of training intervention in healthcare include a lot of vagueness, leaving the reader in doubt about the intervention and the true value of the reported effects. A set of reporting criteria to improve the transparency and comprehensiveness in reporting training interventions in healthcare is recommended. Objective This study aimed to develop and content validate a set of reporting criteria for the development and evaluation of training interventions for healthcare professionals. Method The set of criteria was developed along three stages: (1) a literature review, (2) the design of the criteria, and (3) a Delphi and consensus meeting process with ten experts from different professional disciplines. Results The Criteria for Reporting on Development and Evaluation of Professional Training interventions in Healthcare (CRe-DEPTH) set was systematically developed and consisted of 12 items representing four categories: (1) development of the training, (2) characteristics of the training, (3) characteristics of the providers, and (4) assessment of the training outcomes. Each item has a detailed description to support its unambiguous interpretation. Conclusions The developed CRe-DEPTH reporting criteria guide high quality development, evaluation and reporting for complex training interventions, while preserving the flexibility to incorporate various teaching content or teaching methods. The Cre-DEPTH criteria will allow for detailed reporting on the training, its developmental process, as well as on the rationale for underlying choices, and will avoid non-reporting of training details.

Introduction: Transferring palliative patients between care settings hospital, hospital’s palliative care unit, home and nursing home, is challenging and often hampers integrated care. These transfers are common due to the complexity of palliative care, demographic changes increased prevalence of multimorbidity and higher life expectancy and social changes more people living alone. As a result, transfers require efficient and effective collaboration in order to provide good quality of care. This study is part of a larger research project on integrated care for palliative patients, in a regional palliative care network in Belgium. The study aim was: - to explore healthcare professionals’ experiences of interprofessional collaboration - to explore their perceived factors influencing the continuity of care during palliative patients’ transfer of care setting. Methods: Nine focus group discussions were held, with various professionals GPs, nurses, specialists, psychologists, dieticians, social workers, coordinators. N: 53 from different palliative care settings. Constant comparative analysis was used. Results: Knowing each other personally positively influenced the interprofessional collaboration. Perceptions of hierarchy negatively influenced the interprofessional collaboration, within and between the settings. Timely and sufficient information flow between all professionals involved was considered fundamental. A perceived barrier for interprofessional collaboration was the lack of a shared electronic health record. Efficient multi-disciplinary team meetings with shared care goals were regarded essential, though often lacking. Participants reported that specialists informed the patients on disease stage and prognosis late and insufficiently. This hampered open communication on end-of-life decisions and impeded a timely transfer to the home situation or the palliative care unit. The complexity of patient’s case interfered with the hospitalization length and timely organizing optimal home care the moment of discharge. When transfer to a nursing home was deemed necessary, waiting lists negatively influenced the continuity of care Discussion: Our research shows that several clinical, organisational and service aspects of care at micro-, meso- and macro-level can be improved. At micro-level: insufficient open and timely communication towards the patient, hampers other healthcare professionals’ involvement. Together with absence of shared care goals, this negatively influences a timely referral to other settings. At meso-level: the current electronic health record system does not provide enough opportunities to share and exchange information for professionals involved, within and between the different care settings. At macro-level: continuity of care is hampered when appropriate supply of services lack: e.g., when referral to a nursing home is needed. Conclusions and lessons learned: Doctors should be trained more in bad news delivery and shared decision making. Interprofessional education modules may enhance collaboration and the discussing of shared care goals. Policy makers should invest in sufficient supply of palliative care services and the development of an electronic health record system to provide efficient and effective information transfers between settings. Limitations: We focused on only 1 palliative care network, therefor we are careful to generalize our results. Suggestions for future research: Interventions aiming to improve integrated care within the region will be evaluated.

UNSTRUCTURED Doctors express empathy infrequently and they do not respond sufficiently to patients’ emotional statements. Empathy is compromised even more in cross-cultural and linguistically diverse healthcare settings where doctor-patient communication is mediated by interpreters. Empathy in interpreter-mediated clinical communication has received insufficient attention in medical education and even less in interpreter education. This project aims to develop a research-based educational intervention for undergraduate medical- and interpreting students on empathic communication in interpreter-mediated consultations. The project relies on the Medical Research Council (MRC) framework for the development and evaluation of complex interventions (phases 0-2). Phase 0: 1. Systematic literature reviews on i) complex interventions on clinical communication training between medical students and students from a different field of study, ii) on cross-cultural and interlingual clinical communication training, iii) emotion management in interpreter-mediated consultations. 2. Analysis of video recorded interpreter-mediated consultations by means of the Empathic Communication Coding System (ECCS) and multimodal interaction analysis. 3. Verification of findings by means of video-stimulated recall interviews with doctors, patients and interpreters. Phase 1: Development of training intervention and validation. Phase 2: Feasibility testing and proof-of-concept study/ event. The transfer of the findings into the curricula of both faculties will pave the way for better trained professionals who will be able to co-construct and manage empathic communication more effectively in linguistically and culturally diverse contexts. Both groups of professionals will help improve the health and well-being of patients with linguistically and culturally diverse backgrounds, who might often experience a bias and inequality in the provision of healthcare. Interpreters trained to perform in specialized clinical settings and doctors trained to work in linguistically and culturally diverse settings will enhance the effectiveness and sustainability of hospitals and other healthcare centers and public services in which they operate, contributing, in this way, to better social welfare and social cohesion.

Background : Research suggests that palliative home care should be integrated early into standard care for end-stage COPD patients. Patients also express the wish to be cared for and to die at home. However, a practice model for early integration of palliative home care (PHC) into standard care for end-stage COPD has not been fully developed. Aim : To develop an intervention for early integration of PHC into standard care for end-stage COPD patients. Methods : We conducted a Phase 0-I study according to the Medical Research Council Framework for the development of complex interventions. Phase 0 aimed to identify the inclusion criteria and key components of the intervention by way of an explorative literature search of interventions, expert consultations, and seven focus groups with general practitioners and community nurses on perceived barriers to and facilitators of early integrated PHC for COPD. In Phase 1, the intervention, its inclusion criteria and its components were developed and further refined by an expert panel and two expert opinions. Results : Phase 0 resulted in identification of inclusion criteria and components from existing interventions, and barriers to and facilitators of early integration of PHC for end-stage COPD. Based on these findings, a nurse-led intervention was developed in Phase I consisting of training for PHC nurses in symptom recognition and physical therapy exercises for end-stage COPD, regular visits by PHC nurses at the patients' homes, two information leaflets on selfmanagement, a semi-structured protocol and follow-up plan to record the outcomes of the home visits, and integration of care by enabling collaboration and communication between home and hospital-based professional caregivers. Conclusion : This Phase 0-I trial succeeded in developing a complex intervention for early integration of PHC for end-stage COPD. The use of three methods in Phase 0 gave reliable data on which to base inclusion criteria and components of the intervention. The preliminary effectiveness, feasibility and acceptability of the intervention will be subsequently tested in a Phase II study.

Purpose: Nutrition-related problems are common in patients with advanced cancer. They can disrupt daily life and routines. This study aimed to explore how couples cope with this source of distress. Methods: A qualitative descriptive study design was adopted using semi-structured interviews. Seven couples, each consisting of an advanced cancer patient and his or her co-habiting life partner, participated. The Qualitative Analysis Guide of Leuven (QUAGOL) was used as a guide to facilitate the analysis process. Results: When a patient communicates nutrition-related problems to the partner, individual coping is often complemented by interactive couple-coping pathways, serving two resilient coping strategies: maintaining normality and creating a new normality. These pathways can have either a practical, an emotional or a distant orientation. Different couple-coping pathways can be observed in the same couple when they are dealing with either one or multiple nutrition-related problems. Some couples, however, seem to cope more rigidly, often those with less observed ‘we-ness’. Conclusions: Nutrition-related problems are inherent to advanced cancer and are perceived as health-threatening. Couple-coping with nutrition-related problems is a dynamic and interactive process leaning on different coping pathways. There is no evidence that one pathway is superior to another, as they all serve a resilient coping strategy. Our findings can assist homecare nurses and other professional caregivers in providing psychological support and advice to couples confronted with nutrition-related problems in advanced cancer. Future research should shed light on whether an unsuitable match in coping styles within a couple is one of the precursors of non-resilient outcomes. ispartof: European Journal of Oncology Nursing vol:38 pages:76-84 ispartof: location:Scotland status: Published online

BACKGROUND: Complexity science has been introduced in healthcare as a theoretical framework to better understand complex situations. Interdisciplinary healthcare teams can be viewed as Complex Adaptive Systems (CAS) by focusing more on the team members' interaction with each other than on the characteristics of individual team members. Viewing teams in this way can provide us with insights into the origins of team behaviour. The aim of this study is to describe the functioning of a healthcare team as it originates from the members' interactions using the CAS principles as a framework and to explore factors influencing workplace learning as emergent behaviour. METHODS: An interview study was done with 21 palliative home-care nurses, 20 community nurses and 18 general practitioners in Flanders, Belgium. A two-step analysis consisted of a deductive approach, which uses the CAS principles as coding framework for interview transcripts, followed by an inductive approach, which identifies patterns in the codes for each CAS principle. RESULTS: All CAS principles were identified in the interview transcripts of the three groups. The most prevalent principles in our study were principles with a structuring effect on team functioning: team members act autonomously guided by internalized basic rules; attractors shape the team functioning; a team has a history and is sensitive to initial conditions; and a team is an open system, interacting with its environment. The other principles, focusing on the result of the structuring principles, were present in the data, albeit to a lesser extent: team members' interactions are non-linear; interactions between team members can produce unpredictable behaviour; and interactions between team members can generate new behaviour. Patterns, reflecting team behaviour, were recognized in the coding of each CAS principle. Patterns of team behaviour, identified in this way, were linked to interprofessional competencies of the Interprofessional Collaboration Collaborative. Factors influencing workplace learning were identified. CONCLUSIONS: This study provides us with insights into the origin of team functioning by explaining how patterns of interactions between team members define team behaviour. Viewing healthcare teams as Complex Adaptive Systems may offer explanations of different aspects of team behaviour with implications for education, practice and research. ispartof: Bmc Health Services Research vol:18 issue:1 ispartof: location:England status: published

Background: Involving patients in decision-making is considered to be particularly appropriate towards the end of life. Professional guidelines emphasize that the decision to initiate continuous sedation should be made in accordance with the wishes of the dying person and be preceded by their consent. Aim: To describe the decision-making process preceding continuous sedation until death with particular attention to the involvement of the person who is dying. Design: Qualitative case studies using interviews. Setting/participants: Interviews with 26 physicians, 30 nurses and 24 relatives caring for 24 patients with cancer who received continuous sedation until death in Belgium, the United Kingdom and the Netherlands. Results: We distinguished four stages of decision-making: initiation, information exchange, deliberation and the decision to start continuous sedation until death. There was wide variation in the role the patient had in the decision-making process. At one end of the spectrum (mostly in the United Kingdom), the physician discussed the possible use of sedation with the patient, but took the decision themselves. At the other end (mostly in Belgium and the Netherlands), the patient initiated the conversation and the physician’s role was largely limited to evaluating if and when the medical criteria were met. Conclusion: Decision-making about continuous sedation until death goes through four stages and the involvement of the patient in the decision-making varies. Acknowledging the potential sensitivity of raising the issue of end-of-life sedation, we recommend building into clinical practice regular opportunities to discuss the goals and preferences of the person who is dying for their future medical treatment and care.

Palliative care is a proven approach to enhance quality of life and care both for people with severe chronic obstructive pulmonary disease (COPD) [1] and those with lung cancer [2], and it is encouraged to start palliative care early in the disease trajectory [3, 4]. Similar symptoms occur in both diseases, such as pain, insomnia, fatigue, low mood and dyspnoea [5], with a study reporting even worse physical and emotional functioning for COPD than for lung cancer [6]. These symptoms signal palliative care needs [6], and require treatment focused on symptom management and psychosocial support for more than just the terminal phase. A high use of healthcare resources in COPD is found, related to a tendency towards aggressive and life-prolonging care [7]. Difficulties in predicting disease trajectories and unclear prognosis have been suggested as explanations for why people with COPD are referred less often for palliative care [8]. Palliative care services are used mainly as terminal care in lung cancer and COPD, with less and later use for COPD

Background: Changes in healthcare practice toward more proactive clinical, organizational and interprofessional working require primary healthcare professionals to learn continuously from each other through collaboration. This systematic review uses realist methodology to consolidate knowledge on the characteristics of workplace learning (WPL) through collaboration by primary healthcare professionals. Methods: Following several scoping searches, five electronic bibliographic databases were searched from January 1990 to December 2015 for relevant gray and published literature written in English, French, German and Dutch. Reviewers worked in pairs to identify relevant articles. A set of statements, based on the findings of our scoping searches, was used as a coding tree to analyze the papers. Interpretation of the results was done in alternating pairs, discussed within the author group and triangulated with stakeholders’ views. Results: Out of 6930 references, we included 42 publications that elucidated who, when, how and what primary healthcare professionals learn through collaboration. Papers were both qualitative and quantitative in design, and focused largely on WPL of collaborating general practitioners and nurses. No striking differences between different professionals within primary healthcare were noted. Professionals were often unaware of the learning that occurs through collaboration. WPL happened predominantly through informal discussions about patient cases and modeling for other professionals. Any professionals could both learn and facilitate others’ learning. Outcomes were diverse, but contextualized knowledge seemed to be important. Discussion/conclusions: Primary care professionals’ WPL is multifaceted. Existing social constructivist and social cognitivist learning theories form a framework from which to interpret these findings. Primary care policy makers and managers should ensure that professionals have access to protected time, earmarked for learning. Time is required for reflection, to learn new ways of interaction and to develop new habits within clinical practice.