OBJECTIVES: This is the second of a 2-part article that discusses essential case management practices and strategies amidst the novel coronavirus disease 2019 (COVID-19). The series showcases the potential professional case managers have in support of managing during a crisis such as a global pandemic. Part II continues to describe reenvisioned roles and responsibilities of case managers and their leaders to meet the needs of patients/support systems during the crisis. It focuses on the increased need for end-of-life care, impact on workers' compensation case management practice, and the self-care needs of the professional case manager.
PRIMARY PRACTICE SETTINGS: Applicable to the various case management practice settings across the continuum of health and human services, with special focus on acute care.
FINDINGS/CONCLUSIONS: The COVID-19 global pandemic has resulted in a crisis case managers and other health care professionals never faced something like it before. At the same time, it has provided opportunities for innovation and creativity including use of digital and telecommunication technology in new ways to ensure the continued delivery of health and human services to those who need them regardless of location. It has also resulted in the development of necessary and impactful partnerships within and across different health care organizations and diverse professional disciplines. Most importantly, this pandemic has required special attention to the increased need of patients for timely palliative and end-of-life care. In addition, it has prompted a focus on the safety, health, and well-being of case managers and other health care professionals, resulting in expanded workers' compensation case management practice coupled with the need for self-care and resilience.
IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Professional case managers are integral members of interprofessional health care teams. Their roles and responsibilities are even more necessary during the uncertainty of a global pandemic such as COVID-19. So far, the experience of this crisis has resulted in a deliberate need to ensure the safety of both, those who are the recipients of health care services and those who are responsible for the provision of care. Self-care and resilience of health care professionals and case managers, especially due to the complex dynamics of the COVID-19 pandemic, have advanced a desirable and necessary view of remote/virtual practice and as a strategy for enhancing the person's health and well-being. This pandemic has forced the development of impactful partnerships and collaborations among the diverse contexts of health care organizations and support service providers. These contexts of care delivery have also emphasized the necessary legal and ethical practice of case managers and the other involved parties. Experts agree that the innovative care delivery methods practiced during the pandemic will undoubtedly remain as desirable beyond the current crisis period.
AIM: The aim of this study was to describe team leaders' experiences of facilitators and barriers of leadership in specialist palliative home care teams.
BACKGROUND: For effective teamwork in specialist palliative care, leadership is crucial; however, defining and agreeing on what leadership comprises may be challenging. In palliative care, teamwork is recognized as imperative for multiprofessional perspectives to meet dying patients' and families' needs.
METHODS: Qualitative interviews with 13 team leaders in specialist palliative home care were performed, using the Pettigrew and Whipp framework, and analysed with directed content analysis.
RESULTS: Team leaders' experiences of conditions influencing the organisation and delivery of specialist palliative home care is multifaceted and leaders seem conflicted in their approach to the multiple levels of leadership, vision and responsibilities.
CONCLUSION: Team leaders in specialist palliative home care described goals of care on differing levels and, for some, fiscal restraints and external pressures influenced their vision and leadership. Team leaders experienced challenges of leadership in relation to organisational issues, feeling burdened by responsibilities, budget restraints and team size.
IMPLICATIONS FOR NURSING MANAGEMENT: Team leadership is demanding and complex. In specialist palliative home care, affirming values and enabling vision during times of fiscal strain and external pressures, is challenging. For successful leadership that develops both individuals and the health care team, leaders are recommended to adapt the leadership style to the present situation surrounding the team.
Les codes sous-jacents de la démarche palliative, d’une part, et du management, d’autre part, pourraient paraître antinomiques. Pourtant, l’exercice des managers au sein d’un établissement de santé ou du médico-social est censé côtoyer les principes du care comme mode relationnel avec ses employés. Cet article retrace la genèse de ce questionnement né de la sollicitation d’enseigner les soins palliatifs à des futurs directeurs. En effet, la pratique pédagogique nous a amenés à considérer les soins palliatifs non seulement comme un contenu d’enseignement, mais comme un potentiel modèle managérial intégrant à la fois une vision de co-construction des projets, une implication à tous les niveaux des professionnels, l’empathie dans la relation et la prise en compte de l’impossible.
Prendre son premier poste d'infirmier coordonnateur en Service de soins infirmiers à domicile est un moment nécessitant un encadrement particulier. Des compétences d'encadrement et de gestion sont à acquérir. L'accompagnement par le pair, étant donné la spécificité de ce service, semble obligatoire. Les communautés de pratique peuvent être un appui. L'enjeu de ce travail de recherche est d'étudier en quoi les communautés de pratique sont devenues un accompagnant de la professionnalisation du primo-encadrant en SSIAD ?
[Extrait résumé auteure]
Le déploiement du Système d'Information et du Dossier Patient informatisé suscite craintes et interrogations au sein de l'Hôpital. Le rôle d'accompagnement du cadre de santé est alors essentiel. L'élaboration d'objectifs nécessite une stratégie qui repose sur différents leviers. La phase exploratoire a permis d'établir trois hypothèses répondant à : en quoi une stratégie dans l'accompagnement influence le déploiement du Dossier Patient informatisé ?
Une enquête basée sur une approche qualitative tend à les confirmer ou réfuter. L'étude repose sur l'analyse d'entretiens avec des cadres de santé. A l'issue, il s'avère que le diagnostic est une phase importante pour l'adaptation de l'accompagnement. La responsabilisation, l'implication des professionnels sont de véritables leviers. Cependant la finalité qui favorise l'adhésion n'est pas toujours celle autour de la prise en charge du patient mais plutôt la traçabilité et l'utilisation pratique. Deux autres leviers ont également été éclairés.
Ce mémoire réflexif vient ponctuer deux années riches en partage, en émotions et aussi en introspection. Il part d'une situation managériale complexe qui m'a mise à mal et a fait écho à ma vie personnelle. Elle est venue questionner la vision d'exemplarité que j'avais de ma fonction. En étudiant les concepts des attendus de la fonction cadre, de la vulnérabilité et du mémoire réflexif, je me suis rendue compte que la vulnérabilité n'était pas une faille mais pouvait devenir une force dans les relations humaines si elle est adaptée. Le dernier chapitre est réservé aux déploiements possibles de mes constatations dans ma pratique actuelle : démarche palliative, amélioration du travail pluri professionnel et création d'un temps d'analyse éthique.
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses’ perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
INTRODUCTION: Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.
METHODS: We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies.
RESULTS: Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment.
CONCLUSIONS: These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.
BACKGROUND: Contemporary health policies call for consumers to be part of all aspects of service planning, implementation, delivery and evaluation. The extent to which consumers are part of the systemic decision-making levels of palliative care appears to vary between and within services and organisations.
AIM: The aim of this systematic review is to develop understandings about consumer and carer leadership in palliative care.
DESIGN: A systematic, narrative synthesis approach was adopted due to the heterogeneity of included studies. The review was registered on PROSPERO prospectively (PROSPERO 2018 CRD42018111625).
DATA SOURCES: PubMed, Scopus and PsycINFO were searched for all studies published in English specifically focusing on consumers' leadership in palliative care organisations and systems. Articles were appraised for quality using a modified JBI-QARI tool.
RESULTS: Eleven studies met the inclusion criteria and quality assessment. Consumers are currently involved in leadership of palliative care teaching, research and services. Findings highlight the benefits of consumer leadership in palliative care including more relevant, higher-quality services, teaching and research. Across the included studies, it was not clear the extent to which consumer leaders had influence in relation to setting agendas across the palliative care sector.
CONCLUSION: The findings suggest that more could be done to support consumer leadership within palliative care. Academics and clinicians might improve the relevance of their work if they are able to more meaningfully partner with consumers in systemic roles in palliative care.
PURPOSE: The purpose of this study was to explore compassionate leadership with those involved in leading system-wide end-of-life care. Its purpose was to: define compassionate leadership in the context of palliative and end-of-life care; collect accounts of compassionate leadership activity from key stakeholders in end-of-life and palliative care; and identify examples of compassionate leadership in practice.
DESIGN/METHODOLOGY/APPROACH: Four focus groups involving staff from a range of healthcare organisations including hospitals, hospices and community teams were conducted to access the accounts of staff leading palliative and end-of-life care. The data were analysed thematically.
FINDINGS: The themes that emerged from the data included: the importance of leadership as role modelling and nurturing; how stories were used to explain approaches to leading end-of-life care; the nature of leadership as challenging existing practice; and a requirement for leaders to manage boundaries effectively. Rich and detailed examples of leadership in action were shared.
RESEARCH LIMITATIONS/IMPLICATIONS: The findings indicate that a relational approach to leadership was enacted in a range of palliative and end-of-life care settings.
PRACTICAL IMPLICATIONS: Context-specific action learning may be a means of further developing compassionate leadership capability in palliative and end-of-life care and more widely in healthcare settings.
ORIGINALITY/VALUE: This paper presents data indicating how compassionate leadership, as a form of activity, is envisaged and enacted by staff in healthcare.
PROBLEM: Despite acknowledged benefits, the impact of advance care planning on usual care is inconsistent.
DESIGN: Quality improvement study.
SETTING: A Western Australian regional hospital.
KEY MEASURES FOR IMPROVEMENT: This project aimed to create a system for storing, accessing and incorporating advance care planning documents in clinical care.
STRATEGIES FOR CHANGE: Interventions over 18 months addressed four areas: medical records processes for receiving and processing advance care planning documents; information technology solutions for electronic storage and alerts; clerical staff duties in regards advance care planning documents; and clinician education.
EFFECTS OF CHANGE: There was a 12-fold increase in advance care planning documents stored electronically and 100% of audited notes had correct filing of advance care planning documents with an alert in place at follow-up audit. Clinician recognition of the presence of an advance care planning document improved. Detailed examples of interventions are described.
LESSONS LEARNT: Repeated exposure to different forms of advance care planning education, in conjunction with simple but effective system changes can make a difference in changing established hospital practice. Final impact of these changes on end-of-life care requires further audit.
Liliana de Lima, Executive Director of the International Association for Hospice & Palliative Care (IAHPC), begins by telling me about all the other people I should be interviewing. Her passion for her work and admiration for her colleagues run throughout our conversation, and it soon becomes apparent that the “emotional reasons and rational reasons”, as she calls them, have defined her career.
Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.
L’épuisement professionnel des soignants est particulièrement fréquent en cancérologie. Ses causes en sont plurifactorielles, car relevant quasiment toujours de l’association de facteurs personnels et professionnels. Ceux liés au travail peuvent être séparés en cinq catégories : le type de travail, la charge de travail, les conflits interpersonnels, les facteurs organisationnels et les facteurs managériaux. La qualité de vie au travail est un concept plus récent qui s’inscrit dans le champ de la psychologie positive. La démarche participative est un modèle organisationnel qui reposait initialement sur quatre composantes : la formation interne, les staffs pluriprofessionnels, le soutien aux équipes et la démarche projet. Récemment nous avons rajouté une cinquième composante devant le constat de la nécessité d’espaces d’échanges entre les médecins et les cadres de santé des services pour que le modèle marche. Ce modèle est un critère prioritaire HAS d’accréditation des établissements depuis la V 2010 pour la prise en charge des patients en soins palliatifs dans tous les services de soins. Dans la dernière partie de cet article nous verrons l’impact des facteurs managériaux et organisationnels mais également du modèle organisationnel de la démarche participative sur la qualité de vie au travail des soignants et sur la qualité des soins offerts aux patients et à leurs proches.
Introduction: Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.
Methods: We conducted a literature search in PubMed to identify articles, recent manuals, and clinical practice guidelines on seizure management in PC published by the most relevant scientific societies.
Results: Clinical practice guidelines are essential to identify patients eligible for PC, manage seizures adequately, and avoid unnecessary distress to these patients and their families. Given the profile of these patients, we recommend choosing AEDs with a low interaction potential and which can be administered by the parenteral route, preferably intravenously. Diazepam and midazolam appear to be the most suitable AEDs during the acute phase whereas levetiracetam, valproic acid, and lacosamide are recommended for refractory cases and long-term treatment.
Conclusions: These guidelines provide general recommendations that must be adapted to each particular clinical case. Nevertheless, we will require further well-designed randomised controlled clinical trials including large samples of patients eligible for PC to draft a consensus document recommending adequate, rational, and effective use of AEDs, based on a high level of evidence, in this highly complex area of medical care.
Palliative care has demonstrated effectiveness in alleviating the biological, emotional, social, and spiritual symptoms that accompany serious illness, and improving quality of life for seriously ill individuals and their family members. Despite increasing availability, there are significant disparities in access to and utilization of palliative care, particularly among diverse, low-income, and community-dwelling older adults with chronic illness. Training frontline service providers is a novel approach to expanding access to palliative care among underserved elders. This article presents a process and outcome evaluation of a palliative care curriculum that was developed and piloted for geriatric case managers in a large urban area. We describe the background, planning, design, implementation, and preliminary outcomes associated with a pilot implementation of the curriculum. We conclude with implications for replicating efforts to enhance frontline providers' knowledge, skills, and self-efficacy in extending palliative care to communities that lack access to critical supports for their burdensome symptoms.
BACKGROUND: There is very little research into the way that offender management strategies impinge on the practices and decision-making of palliative care personnel in community settings.
AIMS: To improve understanding of the challenges that community palliative care service providers encounter when caring for people who have been sentenced to custody and are under the supervision of the prison or probation services.
METHODS: This paper discusses one part of a larger multidisciplinary study on bereavement, loss and grief in the criminal justice system. It reports the findings from a focus group with 10 health professionals working within specialist community palliative care services. Thematic analysis was undertaken to identify and explicate the most significant themes arising from the transcript data.
RESULTS: There were situations where the participants were able to identify that patients were under the jurisdiction of the criminal justice system or had relatives in custody. Three themes emerged that highlighted distinctive aspects of providing care to this patient group. These themes were: patients under prison, probation or police supervision altered the dynamics of care provision; prisoners were restricted from supporting or contacting their dying relatives in the community; and participants (professionals) were obstructed from supporting patients at home because of criminal or antisocial behaviour by relatives of the dying.
CONCLUSIONS: Health professionals face multiple challenges that curtail them from fully realising the aims of palliative care for patients and relatives under criminal justice supervision, in ways that merit further consideration and research.
Palliative care has long been described in medical literature but only recently is being discussed in the surgical domain. Mounting evidence suggests that early integration of palliative care improves patient outcomes and this is especially true of oncology patients. Thus, the pendulum is swinging toward recognizing that palliative care and active disease management are not mutually exclusive but rather synergistic in modern surgical oncology. Here we use a patient vignette to demonstrate the new challenges and possibilities in modern surgical oncology, we then discuss the historic perspective of palliative care and describe how the paradigm is shifting. Finally, we introduce a model that may be beneficial in conceptualizing this new way of thinking about and integrating palliative care into surgical oncology.
This article attempts to examine and explore the change management process that was undertaken by the community palliative care service at Calvary Health Care Bethlehem, Australia, to challenge the historical practice of prescribing 'emergency subcutaneous medications' for all patients admitted to the service. It discusses how, using a team approach, change management was effectively facilitated to ultimately enhance service provision and consumer satisfaction. Literature (both national and international) was examined to identify the use of emergency medications in the community palliative care setting. The historical practice of all community palliative care patients being prescribed this medication within the Victoria region of Australia was tested, and concerns and misconceptions of staff and referrers were challenged in regards to this practice. Through working parties, descriptive surveys and staff evaluations, the use of the term 'emergency medication' was changed to 'anticipatory medication' with clear criteria for usage. Change was undertaken slowly and with continued collaboration of staff to ensure effectiveness. Staff survey results identified that the majority were satisfied with the change, and they considered there to be no impact on the quality of care that their patients were receiving. The natural progression of the project, which resulted in positive quantitative and qualitative results, was the facilitation of an education package for carers to educate them on giving subcutaneous medications to the patient. By undertaking change that was slow and methodical with clear communication to all, the community palliative care service was able to embed the changes into everyday practice, and the use of anticipatory medications within the Calvary Health Care Bethlehem community palliative care service is now understood, acknowledged, and adhered to by all staff.