Church Matters: Education About Advance Care Planning and End-of-Life Care in Black Churches.

For many African American adults, the church has the potential to be a place to receive education about advance care planning (ACP). The current study was conducted to (1) identify the frequency of ACP conversations and caregiving and (2) evaluate interest in church-placed end-of-life (EOL) care education. Data were collected from parishioners in 2 African American churches in an urban city in the mid-Atlantic region of the United States. Individuals older than 50 years reported a higher frequency of caregiving ( P < .001) and were more likely to have talked to someone about EOL care ( P < .001) than individuals younger than 50 years. Nearly all respondents considered EOL conversations "important" or "very important" (99.1%) and wanted more information about EOL conversations available via the church (95.8%). Our findings suggest EOL conversations are happening within families and with health care providers, but they are not documented in ways (eg, in writing) that research has focused on previously. Future EOL education will focus more on the importance of documenting and sharing EOL care wishes with family and health care professionals.

A systematic review of interventions for family caregivers who care for patients with advanced cancer at home.

OBJECTIVE: To examine the characteristics of interventions to support family caregivers of patients with advanced cancer. METHODS: Five databases (CINAHL, Medline, PsycINFO, Web of Science, and the Cochrane Library) were searched for English language articles of intervention studies utilizing randomized controlled trials or quasi-experimental designs, reporting caregiver-related outcomes of interventions for family caregivers caring for patients with advanced cancer at home. RESULTS: A total of 11 studies met the inclusion criteria. Based on these studies, the types of interventions were categorized into psychosocial, educational, or both. The characteristics of interventions varied. Most interventions demonstrated statistically significant results of reducing psychological distress and caregiving burden and improving quality of life, self-efficacy, and competence for caregiving. However, there was inconsistency in the use of measures. CONCLUSIONS: Most studies showed positive effects of the interventions on caregiver-specific outcomes, yet direct comparisons of the effectiveness were limited. There is a lack of research aimed to support family caregivers' physical health. PRACTICE IMPLICATIONS: Given caregivers' needs to maintain their wellbeing and the positive effects of support for them, research examining long-term efficacy of interventions and measuring objective health outcomes with rigorous quality of studies is still needed for better outcomes for family caregivers of patients with advanced cancer.

Silent Illumination: A Case Study Exploring the Spiritual Needs of a Transgender-Identified Elder Receiving Hospice Care.

With a growing population of transgender-identified elders in the United States, their unique spiritual end-of-life needs are coming to light. This article presents a case study of a hospice volunteer who used skillful means as an artist to help a transgender-identified woman express her spirituality in the last 6 months of her life. After data analysis, 4 themes emerged related to the expression of spirituality by lesbian, gay, bisexual, transgender, and queer (LGBTQ) elders at end of life. The themes that emerged included (1) the human element in advocacy for spiritual care, (2) the importance of safe spaces for reflection and meditation, (3) the importance of skillful means to work with LGBTQ people, and (4) acknowledgement of gender identity as a spiritual need. This case study serves as a springboard to advance research into the end-of-life needs of LGBTQ elders and the ways in which members of the hospice team can support spiritual care and alleviate suffering for this population.

Community Health Workers and the Management of Noncommunicable Diseases Among Rural Health Clinics in Limpopo Province, South Africa: A Pilot Study.

South Africa's rise in noncommunicable diseases (NCDs) and health care provider shortages has generated the need for community health workers (CHWs) in rural areas. However, roles and interactions with clinic staff are not well understood. Interviews with health care workers at community clinics in Limpopo Province revealed common themes, including resource scarcity, clinic-patient partnerships, management of NCDs, and collaboration between professionals. The data did not support CHW-physician interactions, necessitating further research to describe these practices and to evaluate CHWs' impact on patient outcomes. The CHW involvement in rural clinics is essential to patient-clinic partnerships and may help close treatment gaps in resource-poor areas.

Pain management in home hospice patients: A retrospective descriptive study.

The development and evaluation of evidence-based, safe, and effective home-based pain management models for caregivers implementation is receiving greater attention in the literature because of international initiatives intended to increase the number of people who receive end-of-life care in home-based settings. The purpose of this "retrospective descriptive design" study was to describe pharmacological pain management and outcomes for 40 cancer and non-cancer patients receiving hospice care at home. While the median pain score was higher at admission in the cancer group than in the hospice care at home group, the difference was not significant at or within 48 hour of admission. Overall, there was a significant decrease in pain from the first measurement to the second. Within the last seven days of life, the majority of participants were not able to provide a pain severity score when asked to evaluate the effectiveness of pain management, thus their caregiver provided a proxy evaluation. Pain management was effective in the home setting. More research is needed on the best methods to teach lay caregivers to assess pain and evaluate the effectiveness of pharmacological modalities to manage pain.

Quality of hospice care: comparison between rural and urban residents.

Discrepancies between needed and received hospice care exist, especially in rural areas. Hospice care quality ratings for 743 rural and urban patients and their families were compared. Rural participants reported higher overall satisfaction and with pain/symptom management. Regardless of geographic location, satisfaction was higher when patients were informed and emotionally supported. Patients and family ratings did not differ. Findings support prior reports using retrospective rather than our study's point-of-care surveys.

Palliative care in Thailand.

In Thailand, several barriers exist that prevent people with life-limiting illnesses from accessing good-quality palliative care, namely: lack of palliative care providers; lack of training and education for the palliative care workforce; and issues with availability and distribution of opioids. Without palliative care, people suffer needlessly during the last months of their life. This paper gives an analysis of these issues and provides recommendations for clinical practice, research and health policy that may help to alleviate these issues.

Racial/ethnic perspectives on the quality of hospice care.

Diversity in the US population is increasing, and evaluating the quality of culturally sensitive hospice care is important. A survey design was used to collect data from 743 patients enrolled in hospice or their family members or caregivers. Race/ethnicity was not significantly associated with any of the hospice interventions or outcomes. Patients were less likely to be satisfied with the overall hospice care (OR = 0.23, 95% CI = 0.065-0.796, P = .021) compared to other type of respondents.  Satisfaction with emotional support was substantially associated with the increased likelihood of satisfaction with pain management (OR = 3.82, 95% CI = 1.66-8.83, P = .002), satisfaction with other symptom management (OR = 6.17, 95% CI = 2.80-13.64, P < .001), and of overall satisfaction with hospice care (OR = 20.22, 95% CI = 8.64-47.35, P < .001).

A systematic review of cognitive behavioral interventions in advanced cancer.

OBJECTIVE: To systematically review cognitive behavioral interventions for people with advanced cancer. METHODS: A literature search was conducted using Medline©, CINAHL©, and Psych-info©. INCLUSION CRITERIA: studies were included in the review if they met the following criteria: (1) the design was a randomized clinical trial, (2) the study tested a cognitive behavioral therapy, including psycho-educational, alternative and complementary therapies (i.e. acupuncture, relaxation), expressive, support and skill building interventions, (3) participants were adults (18 years of age or older) with advanced cancer and the (4) outcomes were directly related to the patient with advanced cancer. RESULTS: 11 studies met the inclusion criteria. Of the studies in the review: treatment effects were not statistically significant in most studies, methods were not consistently described, and samples had limited racial/ethnic diversity. CONCLUSION: The interpretation of the effectiveness of the CBIs was limited by major challenges to the internal validity of the studies included in the review. The lack of data about the efficacy of CBIs to support people with advanced cancer is a gap in the current knowledge base. PRACTICE IMPLICATIONS: Given the needs of people living with advanced cancer well-designed studies are needed to test interventions that will improve outcomes for people living with advanced cancer.

Pain management topics of interest for nurses in rural Appalachia.

BACKGROUND: Continuing education for registered nurses is a component of safe, effective pain management in every clinical setting. METHODS: Two hundred ninety-one registered nurses from seven counties in rural southwestern Virginia completed a 22-item survey that assessed their interest in pain management topics. RESULTS: The mean interest score for all respondents was 4.04 (range = 1 to 5). Mean interest scores did not differ significantly between younger and older respondents (t = 1.034, p = .302) or between clinical settings (t = 0.479, p = .632). The mean interest scores for nurses with an associate's degree in nursing/diploma and those with a bachelor of science in nursing or higher were 4.19 and 3.88, respectively, and the difference was statistically significant (t = 3.535, p < .001). CONCLUSION: Nearly 300 registered nurses from communities in the southwestern Virginia area of Appalachia indicated interest in a wide variety of pain management topics. Nurses with at most an associate's degree in nursing/diploma were significantly more interested in pain management education than those with a bachelor of science in nursing or higher degree. The overall interest scores were high, indicating that the respondents found the topics salient to their clinical practice.

Factors That Impact End-of-Life Decision Making in African Americans With Advanced Cancer.

SIGNIFICANCE: African Americans with cancer are less likely to use hospice services and more likely to die in the hospital than white patients with the same diagnosis. However, there is much that is not understood about the factors that lead African Americans to choose options for end-of-life care. DESIGN: A qualitative, descriptive design was used in this pilot study. METHODS: Interviews were conducted with two groups of African Americans with advanced-stage cancer (people enrolled in hospice and those who were not under hospice care). FINDINGS: End-of-life decisions were primarily guided by clinical factors, the patient-related physical, emotional, and cognitive symptoms that are sequelae of the underlying disease or medical treatments. The physician was the healthcare provider most likely to be involved in decision making with patients, family members, and caregivers. Individual factors, such as personal beliefs, influenced end-of-life decision making. Religion and spirituality were a topic in many interviews, but they did not consistently influence decision making. DISCUSSION: Future studies should include interviews with family members, caregivers, and healthcare professionals so that factors that impact end-of-life decision making can be fully described. Strategies to facilitate recruitment will need to be added to future protocols.

Factors that influence the presence of a hospice in a rural community.

PURPOSE: The purpose of this study was to identify socioeconomic, physician-related, and rural-urban factors that may influence the presence of a Medicare-certified hospice in three rural-urban areas. DESIGN: This was secondary analysis of selected socioeconomic, physician-related, and rural-urban data from 3,140 counties using the 2005 Area Resource File, a county-level database. The county was the unit of analysis. METHODS: Descriptive statistics were calculated for selected socioeconomic, physician, and rural-urban variables for the data set of 3,140 counties. Logistic regression was used to identify variables that influenced the presence of a Medicare-certified hospice across three rural-urban areas. FINDINGS: As the rural-urban classification progressed from metropolitan (least rural) to rural-nonadjacent (most rural), the physician rate, racial-ethnic diversity, and number of counties with at least one Medicare-certified hospice decreased. However, in all three rural-urban areas only the physician rate was consistently significantly associated with the presence of a Medicare-certified hospice. CONCLUSIONS: Given the increasing numbers of patients and families who will be facing end-of-life care issues across the globe, access to hospice care is a significant end-of-life outcome. The most rural communities are least likely to have a Medicare-certified hospice. The higher the physician rate, the more likely a county is to have a Medicare-certified hospice. The Medicare Hospice Benefit's regulations requiring a physician's certification of terminal illness may be creating a barrier to hospice care, especially in rural communities. In this study, racial-ethnic diversity decreased as the rural-urban classification progressed from metropolitan (least rural) to rural-adjacent to metro to rural-nonadjacent (the most rural). The availability of Medicare-certified hospices in the metro and rural nonadjacent counties was influenced by the minority composition of the county. More research is needed on how the interaction of rurality, race-ethnicity, and physician access may affect access to hospice in rural communities. CLINICAL RELEVANCE: Increasing numbers of patients and their families across the globe will be facing end-of-life care. One of the most common barriers to end-of-life care in rural communities all over the world is physician availability. People living in rural communities with few physicians may experience less access to the comprehensive services of hospice than people living in metropolitan communities and therefore not realize important end-of-life outcomes such as symptom management, improved quality of life, financial support, and bereavement support.