Context

Systematic reviews and meta-analyses suggest that community specialist palliative care services (SPCSs) can avoid hospitalizations and enable home deaths. But more information is needed regarding the relative efficacies of different models. Family caregivers highlight home nursing as the most important service, but it is also likely the most costly.

Objectives

To establish whether community SPCSs offering home nursing increase rates of home death compared with other models.

Methods

We searched MEDLINE, AMED, Embase, CINAHL, the Cochrane Database of Systematic Reviews, and CENTRAL on March 2 and 3, 2011. To be eligible, articles had to be published in English-language peer-reviewed journals and report original research comparing the effect on home deaths of SPCSs providing home nursing vs. any alternative. Study quality was independently rated using Cochrane grades. Maximum likelihood estimation of heterogeneity was used to establish the method for meta-analysis (fixed or random effects). Potential biases were assessed.

Results

Of 1492 articles screened, 10 articles were found eligible, reporting nine studies that yielded data for 10 comparisons. Study quality was high in two cases, moderate in three and low in four. Meta-analysis indicated a significant effect for SPCSs with home nursing (odds ratio 4.45, 95% CI 3.24–6.11; P < 0.001). However, the high-quality studies found no effect (odds ratio 1.40, 95% CI 0.97–2.02; P = 0.071). Bias was minimal.

Conclusion

A meta-analysis found evidence to be inconclusive that community SPCSs that offer home nursing increase home deaths without compromising symptoms or increasing costs. But a compelling trend warrants further confirmatory studies. Future trials should compare the relative efficacy of different models and intensities of SPCSs.

Background: Impeccable symptom assessment and management is necessary to ensure the optimal quality of life for the ventilated palliative infant and their family. There is a plethora of literature regarding symptom assessment and care when a decision has been made to withdraw ventilatory support. However, there is a lack of literature related to nursing practice for the palliated infant who remains dependent upon ventilatory support until death.

Data sources: CINAHL, PubMed, Elsevier and Proquest Health and Medical Complete databases were searched (2000–2009).

Methods: Seventeen articles were reviewed including: 10 research reports; three literature reviews; two discussion papers; one systematic review and one report documenting the development of a paediatric palliative care programme.

Results: Best practice palliative care requires that care be planned and implemented by an expert multidisciplinary team in collaboration with the infant’s parents who should participate in all levels of decision making to ensure optimal care. The need for impeccable symptom assessment was identified as a key factor in the provision of high-quality symptom control. The assumption regarding a paucity of literature surrounding the continuation of family-centred palliative care for those infants who remain on a ventilator until their death was supported.

Conclusion and relevance to clinical practice: Evidence-based recommendations highlighted in this review may be used as a starting point to formulate neonatal intensive care unit (NICU) clinical guidelines for family-centred palliative care of the ventilator-dependent infant.

Design: An integrative review.

Methods: Searches of key electronic databases and the World Wide Web was undertaken using key words, followed by hand searching for relevant articles. All studies were reviewed by two authors using a critical appraisal tool and level of evidence hierarchy.

Results: The search strategies generated 74 articles, with 10 studies meeting the inclusion criteria. All of these studies evaluated palliative care CPD programmes involving rural nurses which focused on increasing palliative care capabilities. The evidence generated by this review was limited by the absence of randomised controlled trials. A level III-1 study, with a small sample size provided the highest level of evidence, but the lack of control negated the investigators' capacity to confirm causality. Few studies measured the impact of CPD on the quality of care or utilised novel technology to address the tyranny of distance. Despite, these limitations valuable insights into the barriers and facilitators to engaging rural nurses in palliative care learning opportunities were identified.

Conclusions: Evidence that CPD impacts positively on patient and families outcomes is necessary to sustain an on-going investment in learning activities. In order to optimise the opportunities afforded by emerging web-based technology rural nurses' need to develop and maintain their computer competencies. Further investigation of the impact of specialist clinical placements on rural nurses' palliative care capabilities is also indicated.

The role of the general practitioner (GP) and primary health care nurse is fundamental to the provision of high quality care for people living in the community who are approaching the end of their life.

Methods: Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses’ views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective.

Results: A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others.

Discussion: Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.

Objective: To describe interventions to support a palliative care approach in patients with end-stage COPD.

Design: Integrative review.

Data sources and review method: Peer reviewed articles meeting the search criteria were accessed from Medline, PsychINFO, CINAHL and Google Scholar databases as well as Caresearch online resource. The domains of quality palliative care developed by Steinhauser were used as the conceptual framework to synthesise information.

Results: This review has shown that a range of palliative interventions are used to address the needs of individuals with end-stage COPD. Although evidence exists for discrete elements of palliative management in this patient group, there is limited evidence for health service coordination and models that integrate the multiple domains of palliative care with active management.

Conclusion: Further investigation is required to address the complex personal, provider and system elements associated with managing end-stage COPD. A comprehensive and collaborative approach is required to address the complex and varied needs of individuals with end-stage COPD and their families.

Objectives: To establish whether community SPCSs offering home nursing increase rates of home death compared with other models.

Methods: We searched MEDLINE, AMED, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and CENTRAL on March 2 and 3, 2011. To be eligible, articles had to be published in English-language peer-reviewed journals and report original research comparing the effect on home deaths of SPCSs providing home nursing vs. any alternative. Study quality was independently rated using Cochrane grades. Maximum likelihood estimation of heterogeneity was used to establish the method for meta-analysis (fixed or random effects). Potential biases were assessed.

Results: Of 1492 articles screened, 10 articles were found eligible, reporting nine studies that yielded data for 10 comparisons. Study quality was high in two cases, moderate in three and low in four. Meta-analysis indicated a significant effect for SPCSs with home nursing (odds ratio 4.45, 95% CI 3.24–6.11; P < 0.001). However, the high-quality studies found no effect (odds ratio 1.40, 95% CI 0.97–2.02; P = 0.071). Bias was minimal.

Conclusion: A meta-analysis found evidence to be inconclusive that community SPCSs that offer home nursing increase home deaths without compromising symptoms or increasing costs. But a compelling trend warrants further confirmatory studies. Future trials should compare the relative efficacy of different models and intensities of SPCSs.

Background: Changing health care practice is a complex and dynamic process that requires consideration of social, political, economic, and organisational factors. An understanding of the characteristics of the target population, health professionals, and organizations plus identification of the determinants for change are also required. Synthesizing this data to guide the development of an effective intervention is a challenging process. The PRECEDE-PROCEED Model has been used in global health care settings to guide the identification, planning, implementation, and evaluation of various health improvement initiatives.

Design: Using a reflective case study approach, this paper examines the applicability of the PRECEDE-PROCEED Model to the development of targeted chronic care improvement interventions for two distinct Australian populations: a rapidly expanding and aging rural population with unmet palliative care needs and a disadvantaged urban community at higher risk of cardiovascular disease.

Results: The PRECEDE-PROCEED Model approach demonstrated utility across diverse health settings in a systematic planning process. In environments characterized by increasing health care needs, limited resources, and growing community expectations, adopting planning tools such as PRECEDE-PROCEEDModel at a local level can facilitate the development of the most effective interventions.

Relevance to Clinical Practice; The PRECEDE-PROCEED Model is a strong theoretical model that guides the development of realistic nursing led interventions with the best chance of being successful in existing health care environments.

Aim and design: This systematic review aims to examine methods, quality, and results of delirium prevalence and incidence studies in palliative care inpatient populations and discuss implications for delirium screening.

Data sources: A systematic search of the literature identified prospective studies reporting on delirium prevalence and/or incidence in inpatient palliative care adult populations from 1980 to 2012. Papers not in English or those reporting the occurrence of symptoms not specifically identified as delirium were excluded.

Results: Of the eight included studies, the majority (98.9%) involved participants (1079) with advanced cancer. Eight different screening and assessment tools were used. Delirium incidence ranged from 3% to 45%, while delirium prevalence varied, with a range of: 13.3%–42.3% at admission, 26%–62% during admission, and increasing to 58.8%–88% in the weeks or hours preceding death. Studies that used the Diagnostic and Statistical Manual–Fourth Edition reported higher prevalence (42%–88%) and incidence (40.2%–45%), while incidence rates were higher in studies that screened participants at least daily (32.8%–45%). Hypoactive delirium was the most prevalent delirium subtype (68%–86% of cases).

Conclusion: The prevalence and incidence of delirium in palliative care inpatient settings supports the need for screening. However, there is limited consensus on assessment measures or knowledge of implications of delirium screening for inpatients and families. Further research is required to develop standardized methods of delirium screening, assessment, and management that are acceptable to inpatients and families.

Background: Impeccable symptom assessment and management is necessary to ensure the optimal quality of life for the ventilated palliative infant and their family. There is a plethora of literature regarding symptom assessment and care when a decision has been made to withdraw ventilatory support. However, there is a lack of literature related to nursing practice for the palliated infant who remains dependent upon ventilatory support until death.

Data sources: CINAHL, PubMed, Elsevier and Proquest Health and Medical Compltete databases were searched (2000-2009).

Method: Seventeen articles were reviewed including: 10 research reports; three literature reviews; two discussion papers; one systematic review and one report documenting the development of a Paediatric palliative care programme.

Results: Best practice palliative care requires that care be planned and implemented by an expert multidisciplinary team in collaboration with the infant's parents who should participate in all levels of decision making to ensure optimal care. The need for impeccable symptom assessment was identified as a key factor in the provision of high-quality symptom control. The assumption regarding a paucity of literature surrounding the continuation of family-centred palliative care for those infants who remain on a ventilator until their death was supported.

Conclusion and relevance to clinical practice: Evidence-based recommendations highlighted in this review may be used as a starting point to formulate neonatal intensive care unit (NICU) clinical guidelines for family-centred palliative care of the ventilator-dependent infant.

This four-phase mixed method study developed an evidence based “Endotracheal Suction Assessment Tool” (ESAT) as a guide for nurses undertaking “endotracheal tube” (ETT) suction within “Paediatric Intensive Care” (PIC). Phase 1 involved a comprehensive literature review to determine the most commonly used criteria for assessing the need for ETT suction. In Phase 2 an “Endotracheal Suction Questionnaire” (ESQ) was developed to survey experienced PIC nurses in Australia and New Zealand regarding their ETT suction decision making process and validity testing of the ESQ. In Phase 3, the ESQ was administered to target group (n = 104). In Phase 4, the empirical evidence generated from this study, based upon the criteria rated by nurses in this study as being most clinically important and essential during the decision making process, determined the ESAT design. Analyses of quantitative results showed a positive correlation between the perceived frequency of use of a criterion and the appropriateness of the assessment. Where a criterion was used less frequently as a clinical indicator for the requirement for ETT suction, participants had a lower regard for this when rating the criterion as a specific single indicator to perform suction. Findings from qualitative data identified six criteria not previously documented within the literature.

Further testing and validation of the tool within the PIC setting will determine the clinical viability of the ESAT.

Design: The instrument was administered to 405 aged care professionals employed in nine aged care facilities. Exploratory factor analysis and internal consistency statistics were undertaken.

Results: A two-factor solution of the ‘Palliative care self-efficacy scale’ was extracted with factor loadings above the 0.4 cutoff. Cronbach's alpha of the scale and subscales ranged from 0.87 to 0.92. The ‘Palliative care self-efficacy scale’ demonstrates good validity and reliability.

Conclusions: The ‘Palliative care self-efficacy scale’ can be a useful tool in assessing and monitoring clinicians’ perceived capacity to provide a palliative approach. Further evaluation in other samples and settings is required.

Design: Randomised controlled trial.

Population: A total of 330 nulliparous women with unfavourable cervices induced at term.

Methods: Three cervical ripening study arms were used: double balloon catheter (107 women); 16F Foley catheter (110 women) and PGE₂ gel (2 mg) (113 women).

Main outcome measures: Caesarean section, induction to delivery interval, adverse reactions and patient satisfaction.

Results: There was no difference in caesarean delivery rates between groups (double balloon 43%, single balloon 36%, PGE₂ 37%, P = 0.567). The induction to delivery interval was longer in the double balloon group (median 24.5; 95% CI 23.7, 30.6 hours) than the single balloon (23.2; 20.8, 25.8 hours) or PGE₂ (23.8; 21.7, 26.8 hours) (P = 0.043). Uterine hyperstimulation occurred in 14% of the PGE₂ group with none occurring with mechanical cervical ripening. Cord blood gases were worse in the PGE₂ group: median arterial pH double balloon 7.26 (range 7.03–7.40); single balloon 7.26 (7.05–7.44); PGE₂ 7.25 (6.91–7.41) (P = 0.050). Cervical ripening with the single balloon catheter was associated with significantly less pain (pain score ≥4: double balloon 55%, single balloon 36%, PGE₂ 63%, P < 0.001).

Conclusions: Labour induction in nullipara with unfavourable cervices results in high caesarean delivery rates. Although all methods in this study had similar efficacy, the single balloon catheter offers the best combination of safety and patient comfort.