Metasynthesis: Dying adults’ transition process from cure‐focused to comfort‐focused care

Abstract

Aim:To describe and explain the process of transition from cure-focused to comfort-focused health care as perceived and reported by patients, family members, and healthcare providers.Background: Moving into the last phase of life due to advanced illness constitutes a developmental transition with increased vulnerability for patients and family.Design: Qualitative metasynthesis.qualitative designs to report transition experiences of patients, family members, and/ or healthcare providers were included.Review methods: Key elements were extracted and organized into matrices. Findings from each report were analysed using qualitative coding. Results:The sample was 56 unique reports from 50 primary studies. Patients and families emphasized the importance of receiving understandable information, emotional support, respect for personhood and control. The critical juncture of 'realizing terminality' preceded a transition to comfort-focused care. Subsequently, a shift in goals of care emphasizing comfort and quality of life could occur. Continued provision of information, effective support, respect and control promoted 'reframing perceptions' and capacity to embrace a changed identity. Reframing allowed patient and family to find meaning and value in this last phase of life and to embrace the opportunity to prepare for death, nurture relationships, and focus on quality of living. Conclusion:Understanding the developmental process that can be engaged by patients and families at the end of life provides a theoretical basis that can inform choice and timing of interventions to reduce suffering and enhance positive outcomes. K E Y W O R D S comfort care, end of life, literature review, metasynthesis, nursing, palliative care, qualitative research, terminal care, transition

Uncertain trajectories in old age and implications for families and for palliative and end of life care policy and practice

“…Advance care planning and choice about places of care and death are key factors (Meeker, McGinley, & Jezewski, 2019, Roscoe and Tullis, 2015, Fitzsimons et al, 2007 .…”

Transition to comfort-focused care: Moral agency of acute care nurses

“…5,6 Recognizing that one is moving into the last phase of life presents a developmental transition with specific needs, risks, and opportunities. 7,8 For hospitalized patients, this transition is signaled by a change in plan of care from cure-focused to comfort-focused care, which is limited to interventions that are supportive and palliative. Although palliative care can co-occur with curative care, when the care plan is exclusively palliative, medications and other interventions are chosen based only on their contribution to symptom management and overall comfort, rather than having a life-prolonging intention.…”

“…[14][15][16] Because facilitating transitions is an important component of the work of nurses, 17 they enact key roles in caring for patients and families during the transition from cure-focused to comfort-focused care when curative interventions are no longer helpful. Care includes diverse forms of advocating, 16 providing and interpreting information, 8 and facilitating substituted judgment by surrogate decision makers. 14 A recent metasynthesis provides preliminary modeling of the transition process as engaged by patients and describes some of their related needs.…”

“…14 A recent metasynthesis provides preliminary modeling of the transition process as engaged by patients and describes some of their related needs. 8 Well-timed transition to comfort-focused care is dependent on patient, involved family, and care providers coming to a shared recognition that recovery is highly improbable, and agreement on the value and appropriateness of comfort-focused care. 8 While, as noted above, there is evidence describing various nursing roles, there is limited evidence explaining the transition process as a whole from the perspective of nurses themselves.…”

“…8 Well-timed transition to comfort-focused care is dependent on patient, involved family, and care providers coming to a shared recognition that recovery is highly improbable, and agreement on the value and appropriateness of comfort-focused care. 8 While, as noted above, there is evidence describing various nursing roles, there is limited evidence explaining the transition process as a whole from the perspective of nurses themselves. Understanding the specific challenges encountered and strategies that nurses found effective can provide insight and guidance for new nurses and their educators, as well as greater understanding of the nursing role for other clinicians.…”