The population demographics of the greater Toronto Area are rapidly changing, with visible minorities comprising 43% of the GTA, and 10% of the total adult population of Canada. It is incumbent upon the health care sector to accommodate these changes in a culturally competent manner. Health care and culture intersect in the most delicate of ways during the last stages of life. The health care system must ensure that minorities have an equal access to end-of-life health care services and that their individual cultural beliefs and values are respected by culturally competent health care providers. Hence, this thesis examines the current state of cultural competence in hospice and palliative care in the Greater Toronto Area. This study will show the strengths and limitations of the current hospice care in terms of providing culturally competent care. To explore this topic in greater detail, my research is guided by the following questions: 1) What is the current state of culturally competent care in a hospice setting? 2) What are the challenges to providing culturally competent care in a hospice in the Greater Toronto Area? 3) What are some possible strategies for increasing competency within a hospice setting? To explore my research questions fully, I provide a critical analysis of six cultural competency theories, while integrating a social determinants of health framework, focusing on the theory of social exclusion and minority health care. This case study analysis is enhanced by the 14 in-depth interviews of hospice volunteer participants and 1 administrator. There are six major findings in this research. First, volunteer participants encountered cultural clashes when their levels of cultural competency were weak. Second, volunteer participants revealed there was a lack of adequate cultural competency training with the hospice. Third, volunteer participants gave abundant suggestions for improving cultural competency training. Fourth, volunteer participants perceived the hospice to be unsupportive of some of their needs. Fifth, the lack of ethnic, cultural and linguistic diversity of the hospice volunteer participants was noted. Last, the lack of religiosity amongst the volunteer participants was surprising. This research is significant for its Canadian hospice volunteer focus and the findings will be beneficial in practice for patients, their families, volunteers, and other health care providers, by providing the knowledge and tools necessary to enhance their level of cultural competency.

Background: The demand for hospice palliative care (HPC) services is expected to grow due to the increasing number of seniors living into advanced old age, the changing nature of death, and the changing family structure. HPC is a philosophy of care that aims to relieve suffering and improve the quality of life for clients with life-threatening illnesses or end of life issues. The goals of HPC are not only to ameliorate clients’ symptoms but also to reduce unneeded or unwanted medical interventions such as emergency room visits or hospitalizations (ERVH). Hospitals are considered a setting ill-prepared for end of life issues. Therefore, use of such acute care services has to be considered an indicator of poor quality end of life care. It is important to understand the factors that contribute to ERVH in order to determine how to minimize the number of avoidable hospital visits. Objectives: The objectives of this study were to report the proportion of palliative home care clients with ERVH, describe the characteristics of clients with ERVH, and identify the predisposing, enabling, and need-for-care variables associated with ERVH. Methods: Analysis of secondary data was performed on a palliative home care dataset from the Hamilton Community Care Access Centre (CCAC). All palliative home care clients receiving services from the Hamilton branch were assessed using the interRAI Palliative Care (interRAI PC), which is a comprehensive, standardized instrument. One assessment for each client assessed between April 2008 and July 2010 was used, for a final sample size of 764. Results: Half of the palliative home care clients had one or more ERVH. Visits to the emergency department by time of the day and day of the week were relatively stable. Logistic regression and Cox regression analyses showed that wish to die at home and advance care directives are protective against ERVH. Unstable health, identified by a Changes in Health End stage disease and Signs and Symptoms scale (CHESS) score of 3 or higher, was associated with reduced odds of ERVH, while infections such as prior pneumonia and prior urinary tract infections increased odds of ERVH. Conclusions: Predisposing characteristics (i.e., wish to die at home and advance care directives) are nearly as important as need variables (i.e., CHESS and prior urinary tract infection) in determining ERVH among palliative home care clients, which challenges the assumption that need variables are the most important determinants of ERVH. There was a lack of significant association between many assessed needs and ERVH, perhaps due to the fluctuating health status among such clients and the stability of measurements. Ongoing assessment of palliative home care clients is essential in reducing ERVH, as reassessments at specified intervals will allow care and service plans to be adjusted with clients’ changing health needs and end of life preferences.

Purpose/Objectives: To explore the experience and processes of hope for older women who are bereaved palliative caregivers and to develop a substantive theory of their hope experience.<p> Design/Research Approach: Qualitative, constructivist grounded theory <p> Setting: Participants homes in a small Canadian city<p> Sample/Participants: Thirty interviews with thirteen women, ages 60-79, within the first year of bereavement after providing care to a spouse with terminal cancer, also twelve hope diaries<p> Methods/Methodologic Approach: Open-ended, in-depth audio-taped interviews, hope diaries, transcribed verbatim and analyzed using constant comparative analysis<p> Main Research Variables: Participants descriptions of their experience of hope Findings: Participants defined hope as a gradual process of regaining inner strength and building self-confidence, to make sense of their totally changed situations. They were learning to stay positive, and move ahead with their lives. Hope was very important to the participants. The participants main concern was losing hope which they dealt with by searching for new hope through finding balance, finding new perspectives, and finding new meaning and purpose. The theoretical model resembles a spiral and takes place within a social context.<p> Conclusions: Older women who are bereaved after caregiving for a palliative cancer patient are at risk for losing hope and require support as they search for new hope and move through the complex processes of bereavement. <p> Implications for Nursing/Interpretation: Health care professionals can provide appropriate and effective care that facilitates positive and healthy bereavement outcomes by monitoring bereaved palliative caregivers at risk for losing hope and supporting them as they search for new hope to find their own way through bereavement.

Background: Relatives are those persons who are closest to the patient, regardless of relationship and included into the patient´s life world. When a person is in a palliative stage this affects not only the patient but also the relatives, as it implies such a big change in life for all. The nurse has an important role for both the patient and the relatives.  Aim: The aim is to highlight the relative´s needs of support for palliative care.  Method: A literature review based on previous research. Ten articles were found, nine with a qualitative approach and one with both qualitative and quantitative approach.  Results: The analysis resulted in six themes, these were the result of the study. The six themes were, “to be seen an confirmed”, “good communication”, “continuous information”, “availability and continuity”, “to participate” and “to share responsibility with the staff”.  Conclusion: As a nurse we come in contact with relatives of patients in a palliative setting in any form. Our result is useful in all types of care not only in palliative care. It´s much a question of attitude in our performance and attitude is such a large and vital component in health care.

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The purpose of this study is to describe how nurses in Kerala experience the caring of terminally ill patients and how the nurses provide care to promote the wellbeing among these patients. Being terminally ill is threatening for the quality of life and palliative care is important to promote the wellbeing of the patient. The number of immigrants in Sweden is increasing which makes it relevant to study various cultures to acknowledge patients’ different needs and wishes. Six registered nurses in one hospital in Kerala, India, were interviewed. All the nurses had experience of palliative care. The interviews were recorded and analyzed using an inductive approach. Three categories emerged from the analyzed material and they were; loneliness, wellbeing and dealing with work related emotions. It was evident in the result that the nurses found it important to care for the patient’s physical and psychological needs to promote the wellbeing. The result also showed that encountering patients like a fellow human being is essential when treating terminally ill patients, which is especially important to prevent feelings of loneliness. It is important to care for the patient’s emotional and basic needs. To care with a holistic perspective it is essential treat the patient like a fellow human being.

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Introduction: This study compared societal costs of care between two settings of palliative care delivery and death (home versus hospital) in an integrated palliative care program in Toronto. Methods: 186 terminal cancer patients participated in the study. Total societal cost of end-of-life care was compared between patients who died in the home and patients who died in the hospital. Total societal cost of end-of-life care was modeled as a function of the number of days the patients spent at home during the palliative trajectory. Results: There was no statistically significant difference in total cost of end-of-life care between home death and hospital death patients (p>0.05). Furthermore, an additional day the patient spent at home led to a significant increase in the total cost of end-of-life care (p<0.05). Conclusion: The results demonstrated that from a societal perspective, providing palliative care under an integrated palliative care program at home may be just as expensive (if not more expensive) as caring for them in the hospital.

Abstract Background: Palliative radiotherapy (PRT) plays an important role in the management of patients with bone and brain metastases; however, little is known about the use of this treatment in Ontario. Objectives: The objectives of this thesis were to a)identify health system-related and patient-related factors associated with the use of PRT for bone and brain metastases , and b) describe temporal trends in the use of PRT for bone and brain metastases. Methods: The Ontario Cancer Registry was used to identify patients who died of cancer between the years 1984 and 2004. Temporal trends in the use of PRT were described by year and disease site, using the Cochran-Armitage test for trend. A multivariate logistic regression was conducted to describe the relationship between health system-related and patient-related factors, and the use of PRT, while controlling for disease-related factors. Results: Overall, 10.0% and 4.1% of patients dying of cancer received at least one course of PRT within the last two years of life for bone metastases and brain metastases, respectively. The use of PRT for bone metastases significantly decreased from 10.4% to 9.5% (p<0.0001), while the use of PRT for brain metastases more than doubled from 2.2 to 5.1% during the same period (p<0.0001). In the multivariate analysis, age was negatively associated with the use of PRT in both cases. Patients residing in the richest communities were more likely to receive treatment. A farther distance to the nearest cancer was negatively associated with the use of PRT. The level of radiotherapy (RT) services at the diagnosing hospital was positively associated with the use of PRT for bone metastases. Prevailing waiting time did not significantly influence the use of PRT in either case. Conclusions: Over the course of the study period, the use of PRT for bone metastases decreased, while the use of PRT for brain metastases increased. Access to PRT for both bone and brain metastases was influenced by factors unrelated to need. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2009-09-24 23:02:05.662