Critical Appraisal of End-of-Life Care Research Assignment Sample

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Introduction

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This assessment aims to critically assess and evaluate the three chosen articles in relation to the “end-of-life-care”. In this assessment analysis and comparison between three chosen articles will be carried out based on the aim of the research, the methodologies used to identify end-of-life care, and the outcome of the studies. Apart from that, in this assessment, an in-depth evaluation of the existing literature has to be carried out on the chosen topic “end-of-life-care” to address whether the cumulative findings of three research articles can support the existing evidence of the chosen area of nursing or not.

Part 1

(a) Importance and purpose of research governance and ethics

The chosen three articles are based on the core concept of “end-of-life care”. Considering the subject matter of three articles, it can be seen that focus is mainly given to evaluating the tools for improving symptom control and communication between patients and hospital staff. The second article is based on the topic of “ end-of-life” priorities of older adults surviving with terminal illness and caregivers, whereas the third article is based on the topic of analyzing three-step support strategies for patients admitted to the intensive care unit (Resnik, 2020). Therefore, three articles are based on “end-of-life” care strategies and how to provide support to patients who are living with terminal illnesses. In such research studies, research governance and ethics play the most important role, specifically when the sample or respondents for the research studies are older populations and patients admitted to the intensive care unit with a terminal illness. By following proper ethical considerations like alignment and adherence to the Data Protection Act, of 2018, the General Data Protection Regulation of the UK Government can ensure the rights, safety, dignity, and well-being of the participants involved in the study are being protected, and their sensitive or classified information are being kept confidential. Adherence to the ethical principles and research governance standards is also important to carry out research on older populations or in patients living with terminal disorders as it can help to maintain the integrity and trustworthiness of the research process. this is also important to maintain the credibility of the findings and assurance that the results can be relied on by the general public and scientific community (National Institute for Health and Care Excellence 2019). Ethical considerations, like informed consent from the older population, patients admitted to the intensive care unit, or patients admitted to a hospital with a terminal illness, data integrity, and transparency can contribute to the rigor of the study design and reliability of the results.

(b) Aim of the research

The aim of the research conducted on the topic 'Listening to the Family’s Voice: Evaluation of a Tool to Improve Symptom Control and Communication' by McEvoy et al. (2018) is to assess the use of family voices as a mode of daily communication in nine healthcare settings. Healthcare Assignment Help Specifically, the study evaluates the effectiveness of the FV diary communication tool in improving symptom control and communication between patients and caregivers in acute hospital wards and other real-world healthcare environments..

On the other hand, the aim of the second research article carried out on the topic “End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation” (Lewis et al., 2019) is to explore the patient and family experiences and identify the factors that seem to be important to ensure the quality of EOL (end-of-life) care. Therefore, the objective of this article is to define the current priorities among patients and their families for end-of-life care, specifically for older adults, who are living with terminal illnesses. Another important purpose of this article is to elucidate the main components related to the term “quality” in end-of-life care at any hospital setup and explore the possible impact of treatment for the terminal illness on the health, and mental status of the caregivers and care seekers.

The third article is based on “A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomized trial” (Kentish-Barnes et al., 2022). It is seen that inadequate team support for the patients dying at the intensive care unit sometimes increases the prevalence of grief and other psychological impact on the patient’s relatives. Therefore, this study has aimed to evaluate whether proactive and transparent communication between caregivers and the family members of the patient and implementation of support intervention can improve the health and psychological outcome of the relatives in the end-of-life care approach and system process.

(c) Research Methodology, how does the design meet the aims of the study

Two aspects of research design (sampling, data collection, data analysis, bias)

Article 1: Listening to the Family’s Voice: evaluation of a Tool to Improve Symptom Control and Communication”, by (McEvoy et al., 2018),

In-depth evaluation of this research, it can be seen that to evaluate the effectiveness of diary communication as a tool to improve symptom control and communication between the family facing the end-of-life situation and caregivers, the mixed method has been used as the chosen research design. More specifically, in this research practice development approach has been used by incorporating the audit, thematic analysis of the text comments, and collation of written feedback. The justification for using this design for the proposed research is, that this mixed method of research design has allowed the development of a comprehensive understanding of the usability and effectiveness of the chosen intervention in end-of-life care situations (McEvoy et al., 2018). For the recruitment of the data collection sites, help from the Strategic Clinical Network or SCN has been taken, where the palliative care group within the SCN organisation were agreed to promote and take part in the study. More specifically, for this proposed research, the family members of the patients who are in end-of-life care situations were being approached to be respondents or participants for this study, whereas the patients were being selected as the sample for the audit of FV diaries. The sample size for this study was 121, among which 9 diaries were lack of demographic data which means 112 diaries were used as samples for evaluating the impact of diary communication on providing end-of-life care and support to the patients and their families (Mishra and Alok, 2022). For analysis of the data, several frameworks or parameters have been predefined, based on which the perception of family members and patient’s overview of the end-of-life care has been measured.

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The data collection included the demographics of the patients and families, the length of time the diary was used, the date of the diary entries, the time of death along the care plan. For data analysis, the responses were first scored by using the Likert scale, and then thematic analysis was used to identify the raised issues by the families who were in end-of-life situations. To maintain the authenticity of the research study, the effort was made to minimize the bias by obtaining ethical approval, and written consent from the respondents, and training has been offered to the staff who were involved in the data collection and analysis methods. Considering the entire research design and methods, it can be stated that the use of FV rating scales and analysis of the Family’s Voice diaries based on the pre-defined framework have provided an in-depth insight into the effectiveness of family’s voice as communication tool to share the experiences of both patient and families regarding the end-of-life care situation and scenario. the thematic analysis allowed the development of deep understanding on patient’s experiences and their perception towards the importance of using FV rating and diaries to improve the symptom controls and communication at a healthcare setup (McEvoy et al., 2018). On the other hand, the collation of written feedback from principal investigators can provide additional perception regarding how and to what extent the family’s voice and FV diary communication can help the patient and their family express their thoughts regarding the quality of end-of-life care and services expectation from the caregivers in an end-of-life care situation.

Article 2: End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation” (Lewis et al., 2019)

For this proposed article, a primary qualitative research design has been used, where the members of the UNSW consumer EOL advisory group have been used as a sample. The inclusion or eligibility criteria for the sampling for this research were the members of the UNSW consumer EOL advisory group who have direct experiences with health services related to chronic illness including terminal care for themselves or their relatives, experience in providing physical and social care for frail terminal older adults and their relatives towards the EOL were to be selected as sample for the interview. The sample size for the interview was 37, with an age of over 60 years. additionally, for the interview, the sample was selected from the age of 30-49 years who are younger adults and informally cared for the older people. For this proposed research, focus group discussion or FGD or more specifically, in-depth interviews (IDI) have been carried out to address the end-of-life priorities of older adults who are surviving a terminal illness (Lewis et al., 2019). The use of focused group discussion allowed the group dynamics to influence the discussion, whereas the in-depth interviews enabled the inclusion of individuals who were unable to take part in focused group discussion due to health and geographic reasons. Before starting the interview or focused group discussion, written consent was asked from each of the participants. To avoid the biases and manipulation during the interview process, three study team members were organized by taking the staff from psychology background, or nursing background and who were trained in qualitative methods and facilitation of a 90-minute interview or discussion. For the analysis of the transcript, thematic content analysis was employed to identify the key themes and patterns in alignment with the aim of the study (Lewis et al., 2019). The transcripts were managed by using the Nvivo software. Considering the research design, it can be stated that focused group discussion and in-depth interviews can enable the participants to express their ideology or perception regarding the importance of good quality of life in EOL care. Additionally, focus group discussion helped interpret the perception of the caregivers, families, and patients regarding high-quality EOL care along with the identification of the factors with which the quality of care can be improved regardless of the goal of the care (Lewis et al., 2019). For example, an in-depth analysis of this study showcased that as per the caregivers and older adults with terminal illnesses, professional communication, honest consultation on preferences, respect for the dignity of the patient, and support for decision-making related to end-of-life care can improve the relationship between patient, families with the caregivers, which ultimately address the significance of high-quality EOL care. Therefore, the integration of focused group discussion and in-depth interviews has comprehensively explored the end-of-life priorities of older adults with terminal illnesses and caregivers.

 Article 3: A three-step Support strategy for relatives of patients dying in the intensive care unit: A Cluster Randomized Trial, (Kentish-Barnes et al., 2022)

In this article, a prospective, multicentre, cluster randomized controlled trial in 34 ICUs in France has been undertaken as a research method. More specifically, for study design, the COSMIC-EOL cluster randomized trial method has been used to compare the standard EOL care with the proactive intervention in healthcare setup. In this process a three-step nurse-aided, physician-driven support strategy has been used to gather the perception of the withholding and withdrawal decision of the relatives of patients about the EOL treatment. As a sample, the participants were chosen from 34 ICUs in France, and the eligibility criteria for the participants in the randomized trial method were the participants must have experienced treatment withdrawal or withholding decision, and the relatives must have to involved with the ICU team. The participating ICUs were randomly assigned to either intervention or control groups in a 1:1 ratio (Kentish-Barnes et al., 2022). The intervention included 3 conferences between the physicians, and nurses in charge of the patient and the patient’s family members, and the intervention aimed to allow the patient’s relatives to express their emotions, ask questions, and check their understanding regarding the medical information with the assurance that their patient had got the treatment and care until the death. To minimize the bias, the central institution review board approved the study and design protocols, and the study was registered on ClinicalTrials. gov.

Additionally, the data collection method was conducted by a statistician who was not involved in the study. Moreover, the interview was conducted through a telephonic conversation where the trained psychologists were present and who were masked to the group assignment at the time of data collection.

In summary, it can be stated that the cluster-randomized trial, proactive intervention by involving the three-step physician-driven and nurse-aided strategy has helped the researchers to gather perceptions of the relatives of the patients admitted at ICUs for receiving end-of-life care. More specifically, the selected research design has highlighted the fact that the three-step support strategy can significantly reduce the prevalence of prolonged grief among the relatives of deceased patients in comparison to the standard care approach, which in turn can help the researcher to meet the research aim to a considerable extent.

Part 2: Discussion on End-of-Life Care

(a) Critical discussion of the findings

Considering the findings of the first article (McEvoy et al., 2018), it can be summarized that the study aimed to evaluate the importance of using FV or Family View diaries across nine healthcare setups to explore the utility of the tool in facilitating communication and feedback between the clinical staff and families at the time of end-of-life care. considering the entries by the patient’s relatives or families, it can be seen that the majority of the families demanded compassionate care from the hospital staff so that they could respond to the necessity of symptom control. Some of the relatives stated in their diaries that they expected that the staff members would be empathetic and have a good communicative approach, along with maintenance of a clean environment, adequate staffing, and compassionate and integrated care at the hospital setup. Considering the entire findings of this article, it can be stated that the FV diary is an important tool that can offer families an opportunity to provide contemporary feedback to the staff. The feedback from the principal investigators suggested that the FV diaries can improve communication and enhance staff skills in several healthcare setups, although there were concerns in others about the potential family burden and staff reluctance to approach the families. As a whole, the findings stated that the FV diaries os an effective communication tool to improve the quality of end-of-life care in any healthcare setup. On the other hand, the research article by Lewis et al., (2019), has suggested that patient-centered care, which is responsive to the patients’ preferences, needs, and values, regardless of the goal of care is an important tool to improve the quality of end-of-life care in a healthcare scenario. this article contradicts the findings of other two articles, where the communication between patients, family, and caregivers is considered to be the important tool to provide high-quality EOL care to the patient. This study also suggested that early community-based palliative can also enhance patient satisfaction and increase the likelihood of dying at home. Considering the third article and its findings (Kentish-Barnes et al., 2022), it can be summarised that a three-step physician-driven and nurse-aided strategy can significantly reduce the prevalence of prolonged grief among bereaved relatives in comparison to the standards of care. the intervention has included effective communication, and the research findings stated that communication can be used as an effective tool to support the patient by improving the quality of end-of-life care. the findings also suggested that the effective use of communication can show promising outcomes to improve end-of-life care and support for the relatives of patients who are in end-of-life situations.

(b) Evaluation of the literature on EOLC- Literature supports or disagrees with the findings

Considering the themes of the three chosen articles, it can be stated that hospitalisation and management of patients at the end of life by emergency medical intervention are always considered to be challenging, as the majority of the people who are at terminal illness or approaching death, want to die at home. Considering several other research articles or existing literature reviews, it can be seen that, apart from the use of effective communication or three-step proactive and nurses aided strategies, symptoms management, Bereavement support, and advance care planning are important strategic implementations with which the healthcare providers can provide high-quality end-of-life care services to the people with a terminal illness and their family members (Curtis et al., 2013). According to Forero et al., (2012), despite the communication and coordination, it is of foremost importance to assess and treat the patient’s physical and psychological symptoms in end-of-life situations. Symptom management can improve the comfort and well-being of patients, which can also involve the use of palliative medication, non-pharmacological interventions, and complementary therapies. According to another research by McEvoy et al., (2018), most of elderly patients have multiple health problems and comorbidities which results in the “committee” medicine with little coordination or leadership to initiate the discussion regarding the value of continuing conventional medicine. A structured approach to decision-making can considered as one of the best possible supports for both the patient and families at end-of-life care, which includes the prognosis, risk-benefits analysis, and intervention that take the current symptom burden and patient age, life stage, and goal of care into account (Piva et al., 2019). NICE or National Institute for Health and Care Excellence provides an evidence-based guideline and advice to health and social care workers in the UK in reference to the provision of end-of-life care.

 According to the NICE guideline, it should be important for healthcare workers to provide improved end-of-life care to people with terminal illnesses which can be done by communicating with them respectfully and involving them in the decision-making process. thus guideline also covers how to manage the common symptoms without causing any unacceptable side effects for the patient with a terminal illness (National Institute for Health and Care Excellence 2019). Considering the NICE guidelines, the current literature reviews, and the findings of chosen articles, it can be concluded that, every research and guideline stated a similar notion, that palliative care is one of the best-fit strategies to improve the quality of end-of-life care (Weber, 2019). Hospice UK also provides an overview regrading the key principles, and policies or guidance regarding palliative and end-of-care (PEoLC) across the UK. The “Ambitions for Palliative and End of Life Care” outline the responsibilities of healthcare providers to provide priorities on improving care during the critical phases of life. This intervention policy also stresses personalized care, integrated care approach, and collaboration to improve the quality of care and support for patients and their families in end-of-life situations. Communication, coordination, nurses-aided strategies, and other integrated clinical interventions are an integral part of palliative care with which the caregivers can offer high-quality support to both the patients and their families at the end-of-life situation.

Limitation

Upon comparison of three different articles, it can be stated that the cumulative limitation of these articles are the variability in the implementation of standard care practices in ICUs, which can impact the comparison with the intervention groups. Additionally, in these articles, focus has only given on using proactive communication as a support intervention for improving the end-of-life care services quality for patients, and their families. Therefore, these researches are lacking in including the importance of other factors or the significance of holistic palliative care or collaborative participation of different stakeholders to improve overall end-of-care service qualities for the patients and their families. Additionally, considering these three articles, another limitation is the lack of direct interviews with the patients and families who are receiving end-of-life care services or in End-of-life situations regarding how communication and proactive strategies can help them to get improved care as per their needs.

Conclusion

In this assessment, a critical evaluation of three chosen articles on end-of-life care approaches has been carried out, by emphasizing the importance of research governance, ethics, and methodological alignment with the aims of the articles. In this assessment, the key focus has also been given to the findings of the chosen articles which highlighted the significance of communication and communication tools and proactive strategic approaches to improve the quality of end-of-life care for the patients and their families. Each study has offered valuable insights, by collaboratively underscoring the important role of integrated and palliative care, personalized approach, and interdisciplinary collaboration to meet the complex needs of patients who are in terminal illness and their families.

References

• Curtis, J.R., Downey, L. and Engelberg, R.A. (2013). The Quality of Dying and Death. Chest, 143(2), pp.289–291. doi:https://doi.org/10.1378/chest.12-1941.
• Flick, U., (2015). Introducing research methodology: A beginner's guide to doing a research project. Sage. https://books.google.co.in/books?hl=en&lr=&id=jcOICwAAQBAJ&oi=fnd&pg=PP1&dq=textbook+on+research+methodology&ots=rtNBfT68dV&sig=zsmZM_b42kOTX2NybCq1JcvMfU4&redir_esc=y#v=onepage&q=textbook%20on%20research%20methodology&f=false
• Forero, R., McDonnell, G., Gallego, B., McCarthy, S., Mohsin, M., Shanley, C., Formby, F. and Hillman, K. (2012). A Literature Review on Care at the End-of-Life in the Emergency Department. Emergency Medicine International, [online] 2012, pp.1–11. doi:https://doi.org/10.1155/2012/486516.
• Kentish-Barnes, N., Chevret, S., Valade, S., Jaber, S., Kerhuel, L., Guisset, O., Martin, M., Mazaud, A., Papazian, L., Argaud, L., Demoule, A., Schnell, D., Lebas, E., Ethuin, F., Hammad, E., Merceron, S., Audibert, J., Blayau, C., Delannoy, P.-Y. and Lautrette, A. (2022). A three-step support strategy for relatives of patients dying in the intensive care unit: a cluster randomised trial. The Lancet, 399(10325), pp.656–664. doi:https://doi.org/10.1016/S0140-6736(21)02176-0.
• Lewis, E.T., Harrison, R., Hanly, L., Psirides, A., Zammit, A., McFarland, K., Dawson, A., Hillman, K., Barr, M. and Cardona, M. (2019). End-of-life Priorities of Older Adults with Terminal Illness and caregivers: a Qualitative Consultation. Health Expectations, 22(3), pp.405–414. doi:https://doi.org/10.1111/hex.12860.
• McEvoy, M., Scott, E., Blenkinsopp, J. and Hamilton, S. (2018). Listening to the family’s voice: evaluation of a tool to improve symptom control and communication. International Journal of Palliative Nursing, 24(11), pp.548–557. doi:https://doi.org/10.12968/ijpn.2018.24.11.548.
• Mishra, S.B. and Alok, S., (2022). Handbook of research methodology. http://74.208.36.141:8080/jspui/bitstream/123456789/1319/1/BookResearchMethodology.pdf
• National Institute for Health and Care Excellence (2019). Overview | End of Life Care for adults: Service Delivery | Guidance | NICE. [online] Nice.org.uk. Available at: https://www.nice.org.uk/guidance/ng142.
• Piva, S., Fagoni, N. and Latronico, N. (2019). Intensive care unit–acquired weakness: unanswered questions and targets for future research. F1000Research, 8, p.508. doi:https://doi.org/10.12688/f1000research.17376.1.
• Resnik, D.B. (2020). What Is Ethics in Research & Why Is It Important? [online] National Institute of Environmental Health Sciences. Available at: https://www.niehs.nih.gov/research/resources/bioethics/whatis.
• Weber, M. (2019). HelpGuide.org. [online] HelpGuide.org. Available at: https://www.helpguide.org/articles/end-of-life/late-stage-and-end-of-life-care.htm.
• Zahuranec, D.B. and Creutzfeldt, C.J. (2020). Surviving Severe Stroke—Our Next Big Challenge. Circulation: Cardiovascular Quality and Outcomes, 13(12). doi:https://doi.org/10.1161/circoutcomes.120.007523.