Our objective was to examine the impact of palliative care (PC) on aggressive care near death for patients with advanced pancreatic cancer. Measures of aggressive care included (i) chemotherapy within 14 days of death; (ii) more than one emergency department (ED) visit; (iii) more than one hospitalization; and (iv) at least one intensive care unit (ICU) admission, all within 30 days of death. A retrospective population-based cohort study was conducted with patients diagnosed with advanced pancreatic cancer in Ontario. Multivariable logistic analyses were performed. Our final cohort consisted of 5,381 patients (median survival of 75 days). 52% received a PC consultation. PC consultation was associated with decreased use of chemotherapy near death (OR=0.34); and lower risk of ICU admission (OR=0.12), multiple ED visits (OR=0.19), and multiple hospitalizations near death (OR=0.24). A per unit increase in the monthly rate of PC visits was associated with lower odds of aggressive care.

Our objective was to examine the impact of palliative care (PC) on aggressive care near death for patients with advanced pancreatic cancer. Measures of aggressive care included (i) chemotherapy within 14 days of death; (ii) more than one emergency department (ED) visit; (iii) more than one hospitalization; and (iv) at least one intensive care unit (ICU) admission, all within 30 days of death. A retrospective population-based cohort study was conducted with patients diagnosed with advanced pancreatic cancer in Ontario. Multivariable logistic analyses were performed. Our final cohort consisted of 5,381 patients (median survival of 75 days). 52% received a PC consultation. PC consultation was associated with decreased use of chemotherapy near death (OR=0.34); and lower risk of ICU admission (OR=0.12), multiple ED visits (OR=0.19), and multiple hospitalizations near death (OR=0.24). A per unit increase in the monthly rate of PC visits was associated with lower odds of aggressive care.

People with advanced cancer may have significant challenges to their physical, emotional, spiritual, and social well-being. However, some individuals are able to experience an overall sense of well-being in spite of these challenges. This study sought to understand the experience of well-being from the perspective of people with advanced cancer. Guided by interpretive descriptive methodology, eight participants were interviewed and the data were analyzed using the constant comparative approach. The participants took an active role in their well-being experience and described four main themes: view of self, the fluctuating nature of well-being, choices made to enhance well-being (including choosing supportive relationships, putting one‟s own needs first, treatments, focusing on the positive, and honoring the negative), and living in ambiguity. These findings have implications for nursing practice, nursing education, and health care organizations. / Graduate

This thesis demonstrates relations among health, social network, ADL and patterns of care in the oldest old guided by a resource theoretical model. The analyzed data are based on two studies: the Nona study, a longitudinal study of 157 individuals aged 86 to 94 years, and the H70 study, a longitudinal study of 964 individuals aged 70 at baseline. Data were collected by interviews and to some extent in the H70 study, medical exams and medical records. The results demonstrate that perceived resources seem to affect patterns of care to a higher extent than the more objective resources in the sample of the oldest old. On the other hand, sociodemographic variables such as gender, marital status and SES, in addition to the more objective resources of having children nearby and the number of symptoms of illness predicted institutionalization during a subsequent 30-year period from the age of 70. The proportion of elderly persons’ institutionalization was further significantly higher than that generally found in cross-sectional studies. ADL was one of the strongest predictors for both use of formal care and institutionalization in both samples, indicating an effective targeting of the formal care system in Sweden. The care at end of life in the oldest old is challenged by the problems with progressive declines in ADL and health, which makes it hard to fit in the dying oldest old in the palliative care system. There is a need to increase the knowledge and the possibility for care staff to support and encourage social network factors and for decision-making staff to consider factors beyond ADL.

abstract: Over recent decades, euthanasia has been a topic of increasing debate. With legalization of euthanasia in the states of Oregon and Washington and attempted reform in several other U.S. states and nations worldwide, it has become increasingly important to understand the roles and values of helping professionals who might be working with clients considering this option. The current study targeted 85 undergraduate students, 54 doctoral students in counseling psychology, and 53 doctoral-level professionals in psychology to assess both their personal values regarding euthanasia and their willingness to allow a client the autonomy to make a decision about euthanasia. Several factors were analyzed in regards to their relation to client autonomy and attitudes toward euthanasia, including age of client and sex of client. These variables were manipulated in vignettes to create four scenarios: a 24 year old male, 24 year old female, 80 year old male, 80 year old female. Other factors included level of education of the participant, spirituality and strength of religiosity of the participant, and personal experiences with deaths of friends or family members. Results indicated that more education was associated with greater support for euthanasia and that stronger religiosity and spirituality were related to less support for euthanasia. This study also found that participants did not exhibit differential levels of support based solely on the age or the sex of the client depicted in the vignette. Results further indicated that for doctoral students and professionals the loss of a loved one, regardless of cause of death, did not have a significant effect on their attitudes toward euthanasia. It is important for training programs to be aware of these findings in order to monitor trainees in terms of personal biases in the therapy relationship. With objectivity a high priority while working with clients, it is necessary to be aware of outside factors potentially influencing one's work with clients surrounding this value-laden issue. / Dissertation/Thesis / Ph.D. Counseling Psychology 2011

This qualitative phenomenological study attempts to gain the physician's essences, meanings and understanding surrounding death and dying. Starting with themes revealed in literature, in-depth interviews were used to ask selected physicians providing care: How does death affect them? Are physicians receiving adequate training in end-of-life care? Does the medical culture still see death as failure? How do they find meaning in end-of-life care? Using three different groups of physicians: early in career, mid-career, and retired, this research attempted to examine the phenomena of death and dying over apparent time and developmental experiences of physicians. Results: Physicians have not been adequately trained to handle end-of-life care. Communications skills, specific end-of-life care training and support for physicians dealing with death and dying are needed.

Meeting the heath care needs of patients is becoming more complex as individuals are living longer and often with multiple chronic health conditions. In Canada, the majority of patients will die in hospitals (Statistics Canada, 2009), many on medical units. Studies of hospital care have shown that end-of-life care (EOLC) could be improved. Qualitative nursing research studies on EOLC in hospital medical units have been few. More needs to be known about nurses’ experience of providing EOLC within the medical unit environment. The purpose of this study was to seek to understand the lived experience of nurses on a medical unit providing EOLC to patients. Interpretive phenomenology using van Manen’s (1990) approach guided the methodology and analysis of the findings. Face to face interviews with 10 nurses on two hospital medical units were audio-recorded, transcribed and analyzed. The underlying essence of these nurses’ experience was that of “battling a tangled web”. Battling a tangled web represented the nurses’ struggles in attempting to provide EOLC in an environment which was not always conducive to it. Seven themes were generated from the analysis of the data: caring in complexity, caught in a tangled web, bearing witness to suffering, weaving a way to get there: struggling through the process, creating comfort for the patient, working through the dying process with the family, and finding a way through the web. These findings add to our growing knowledge of nurses’ roles and actions as part of EOLC. It also highlights nurses’ perceived facilitators and barriers to EOLC within the medical environment.

Background: Advance care planning (ACP) is a method used for patients to express in advance their preferences, beliefs and values for life-sustaining treatments at the end-of-life. With growing ethnocultural diversity in Canada, health care providers are managing an increasing number of diverse beliefs/values that are commonly associated with preferences for mechanical ventilation (MV) at the end-of-life. The aim of this project is to explore methods used by health care providers to set care plans for MV with ethnocultural populations. Methods: Qualitative analysis of semi-structured interviews with open-ended questions and two clinical vignette components was conducted with eight (8) health care providers who engage in ACP. Participants were recruited using a snowball-sampling approach from five acute-care hospitals within the Ottawa region. Results: Three major themes emerged from collected dataset: 1) Goals of care across illness trajectories, 2) Respecting beliefs, values, and wishes for care, and 3) Cross-cultural support in ACP. Using a value-based approach in ACP was described as an effective method for managing and interpreting diverse beliefs/values that impact decisions for MV. However, organizational, systemic, and personnel barriers that exist continue to hinder the provision of cross-cultural ACP across health settings. Contexte: La planification préalable des soins (PPS) est une méthode utilisée par les patients et les familles pour exprimer à l'avance leurs préférences liées aux traitements de prolongation de vie. En raison de la diversité ethnoculturelle croissante au Canada, les professionnels de la santé sont confrontés à des croyances et valeurs différentes, souvent associées à une préférence pour l’initiation et le maintien de la ventilation mécanique (VM) en fin de vie. L'objectif de ce projet consiste à explorer les stratégies utilisées par les professionnels de la santé lors des discussions associées à la VM auprès d'une clientèle multiculturelle. Méthodes: Huit (8) participants (médecins et infirmières) impliqués dans la PPS ont accepté de participer à une entrevue semi-structurée avec des questions ouvertes et deux scénarios cliniques. Les participants ont été recrutés à l'aide de la méthode d’échantillonnage par réseau (« boule de neige ») de cinq hôpitaux de la région d'Ottawa. Résultats: Trois grands thèmes ont émergé des entrevues: 1) les objectifs de soins à travers les trajectoires de la maladie, 2) le respect des croyances, valeurs et souhaits pour les soins, et 3) le soutien dans la PPS en contexte interculturel. Lors de la PPS, utiliser une approche basée sur les valeurs a été décrite comme une méthode efficace pour interpréter et prendre en compte les diverses croyances et valeurs qui ont une influence sur les décisions liées à la VM. Cependant, les barrières systémiques, organisationnelles et personnelles continuent d'entraver les services associés à la PPS en contexte interculturel dans les établissements de santé.

In the medical context, it is an accepted (yet controversial) fact that doctors may sometimes legitimately hasten death when providing palliative care to dying patients. Or even, in relation to treatment decisions leading to withdrawal or omission, some doctors may choose death over life for certain patients and yet we seldom hear of doctors in the dock for intentional killing. Where complicity in suicide is concerned, it seems that the compassionate lay person has little reason to be fearful of criminal reprisal. The question, however, of whether a person suspected of complicity in suicide, or a doctor suspected of intentionally causing the death of a patient, will be greeted by sympathy or condemnation is a legal minefield. A range of diverse legal, moral and circumstantial factors will determine firstly, whether one is prosecuted and secondly, whether one will be subject to juridical disapproval and possible incarceration. This thesis sets out to explore whether continued obfuscation, together with turning a blind eye to possible breaches of the law, is the best approach to the moral dilemma over what should be permitted in assisted dying and end-of-life law. This is not a rhetorical question with a trite answer. Such obfuscation may be viewed as having certain advantages. This thesis explores the legal and ethical issues in the context of recent developments, societal concerns and international influences in order to examine whether the current legal position in respect of homicide and complicity in suicide is tenable. The analysis invites the conclusion that whilst some legal change is both desirable and necessary, any legal reform should seek to facilitate a cautious compromise that reflects the legitimate concerns of those opposed to legal change.

Community health care aides form the largest group of home health care providers in Canada. There is an increasing trend in Canada towards more home deaths. Home Care and the health care aides that provide this care are an integral component of this movement. An Interpretive Descriptive study was undertaken to identify community health care aides’ experiences of support as they provide end-of-life care to those dying at home. Three themes emerged from the data: 1) Striving to provide the best care, 2) Connections, and 3) Loss. Findings suggest that relationships form an important part of the health care aides' work and are intertwined throughout all the themes identified in this study. Health care aides in the community often feel undervalued and unsupported by the larger health care team. Comparatively little research has been undertaken to examine the unique experiences of the community health care aides providing end-of life care, compared to research on the health care aides providing end-of-life care in the long-term care setting and to research on nurses providing end-of-life care in the community. Community health care aides have unique challenges and characteristics and this study was undertaken to address this gap. / Graduate