PICOT STATEMENT AND LITERATURE SEARCH

Topic: 

Determining the effectiveness of nursing home-based palliative care for patients with terminal illness as compared to home-based care in improving quality of life

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Clinical Issues

Pain

One of the main problem that most patients with terminal illness experiences is pain. This affects the behavior of the patients as well as the intervention to be offered to them. Freedom from pain has been noted to rank highest among the considerations of end-of life process for most patients with terminal illness. Pain, especially cancer-related pain, is common among the patients with advanced diseases and needs to be managed either using the analgesic measures or through other interventions.

Depression 

Most patients with terminal illness offer experience psychological distress. It is estimated that about 45% of the terminally ill patients with cancer experiences depression which is positively associated with suicidal thoughts. The presence and severity of the clinical depression are said to affect the severity of physical illness. Indicators for depression may include, progressive inability to get out of bed, a reduced appetite, anxiety, and demoralization.

Coping

Patients with terminal illness experience the challenge of coping with their condition. Patients who can be noted to be good copers portray optimism, practicality, resourcefulness, awareness and flexibility. Poor coping ability among the patients with terminal illness leads to defensive behaviors such as isolation, projection, noncompliance, avoidance, and denial. Non-compliance is the major thereat to attaining favorable outcomes for unfavorable outcomes in psychopharmacology. 

Dignity

Some patients with terminal illness have a major concern in the preservation of dignity by upholding their honor, respect, and esteem. Dignity, to most of these patients, is seen to directly relate to the degree of independence and autonomy that the patients retain in the period of their illness. The factors that help in promoting dignity among the terminally ill patients include functional capacity, cognitive acuity, symptom management and reduction in psychological distress. It is also important to manage medical uncertainty and anxiety.

The need of Control 

Some category of the terminally ill patients, emphasizes on the need to maintain a sense of control in the dying process. The need for control is most common among patients who ask for physician-assisted suicide in areas where that is legal. Such patients want to receive the palliative care in a place that can accommodate their strong personalities exhibited by a determination and inflexibility in the choices that they make.

PICOT Statement

Population: Patients with terminal illness

Intervention: Nursing home-based palliative care

Comparison: Home based palliative care

Outcomes: Increased quality of life 

Time-Frame: Last 3 months

Research Question 

Does nursing home-based palliative care among the patients with terminal illness increase the quality of life compared to home based care?

Reference list

Aoun, S., Slatyer, S., Deas, K., & Nekolaichuk, C. (2017). Family caregiver participation in palliative care research: challenging the myth. Journal of pain and symptom management53(5), 851-861.

The article observes that despite the many international guidelines highlighting the importance of consumer directed care and autonomous decision in engaging in research, there exists a common misguided notion that participating in research among the patients and family members does not impact on improvement of quality of life but rather leads to increase in unwanted burden. The research was carried out and it involved the family caregivers of terminally ill people under home-based palliative care. The research was carried out among 316 participants and had both the quantitative and qualitative aspect. The study provided evidence that challenged the misconception indicated. The family caregivers appreciated being part of research as their considered this as beneficial in helping improve the quality of life of their patients.

Brumley, R., Enguidanos, S., & Hillary, K. (2003). Effectiveness of Home-Based Palliative Care Program for End-of-Life. Journal of Palliative Medicine, 715-724.

It is noted that there is a widespread need of developing new model targeting to better serve the patients at the end-of-life. This article sought to evaluate the effectiveness of home-based palliative care program for end-of-life. The study is a quantitative study conducted over a period of two years, with two groups being enrolled, a palliative care program with 161 participants and comparison group with 149 participants. The program used was the Kaiser Permanente Palliative care project. The findings indicate that the palliative care patients noted an increase in level of satisfaction with services offered after 60 days into the project. The outcomes of the program include less emergency department visits, hospital days, skilled nursing facility days, and physicians as compared to the comparison groups. The integration of palliative care into the curative care practices in early stages was noted to lead to higher levels of satisfaction with the care as well as reduction in costs of care.

Gomes, B., Calanzani, N., Curiale, V., McCrone, P., & Higginson, I. J. (2009). Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane database syst rev6.

The article observed that 50% of the people would prefer being cared for at home but yet only about a third of deaths actually take place at home. This article conducts a systematic review of research articles that included randomized controlled trials (RCTs), controlled clinical trials, controlled before and after studies, and interrupted time series. The article sought to quantify the effects of home palliative care services for patients with advanced illness, examine the clinical effectiveness of home palliative care services, and compare resource use and costs that arise with these services. Results pointed out that home palliative care increases the chances of dying home and reduces the symptom burden especially for the patients with cancer without impacting on caregiver grief. This justifies the need to advocate for home palliative care for patients whose choice would be to die at home. 

Hasson, H., & Arnetz, J. E. (2008). Nursing staff competence, work strain, stress and satisfaction in elderly care: a comparison of home‐based care and nursing homes. Journal of clinical nursing17(4), 468-481.

It is observed that there has been a shift in trend in old people care from hospitals to homecare. This is said to have effects of the nursing practice in terms of lack of competence development, increased levels of work strain, and low levels of work satisfaction among the nursing staff. This article’s aim was to compare how the old people care nursing staff perceives their competence, work strain, and work satisfaction in nursing homes and home-based care. It also sought to establish the determinants of work satisfaction in both care settings. A cross-sectional design was utilized to achieve these aims. Comparison was made between the two care settings. From the results, it was noted that staff in home care had significantly less knowledge relative to staff in nursing homes. The ratings on work exhaustion, mental energy, and work satisfaction seemed to almost similar for the two care groups. The nursing staff noted that work-related exhaustion was the main indicator that negatively affected the work satisfaction. 

Greer, J. A., Pirl, W. F., Jackson, V. A., Muzikansky, A., Lennes, I. T., Heist, R. S., … & Temel, J. S. (2011). Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non–small-cell lung cancer. Journal of Clinical Oncology30(4), 394-400.

The research noted that previous studies had indicated that introducing palliative care early after diagnosis among patients with lung cancer led to improvement in quality of life, mood and survival. The study also aimed at influencing the frequency and timing of chemotherapy use and hospice care for the patients. The study conducted was a randomized control trial where 151 participants. The results indicated that early palliative care optimized timing of final chemotherapy administration and transition to hospice services and key measures of quality end-of-life care

Peters, L., & Sellick, K. (2006). Quality of life of cancer patients receiving inpatient and home‐based palliative care. Journal of advanced nursing53(5), 524-533.

The article involved a comparative study of the symptom experience, physical and psychological health, perceived control of the effects of cancer and quality of life of terminally ill cancer patient receiving inpatient and home-based palliative care and factors that point out to quality of life. Quality of life is regarded a major goal in the care of patients with terminal cancer. The study involved fifty-eight patients with terminal cancer with 32 in the hospital-based care and 26 in the home-based. The most prevalent symptoms indicated weakness, fatigue, sleeping during day and pain. Patients under home-based services had statistically significantly less symptom severity and distress. Lower depression scores, better physical health, and quality of life than those receiving inpatient care. The home care patients also had more control over the effects of their illness.

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