PICO Questions Associated With Palliative Care: Summative Assessment 1 Answer

Answer :

Introduction

This paper starts with identification of a PICO question associated with the field of palliative care and move ahead with searching an appropriate database to identify some of the key sources of information or citations that will help in identifying the answer to the question. A suitable search strategy ensures narrowing down of search results and obtains most precise citations. Therefore, the paper also provide some tips for other students to select proper database followed by appropriate keywords, MeSH strategy, Boolean strategy or other strategies to conduct effective research based on the identified PICO question. 

PICO Question

Is there an impact of palliative care interventions on improving the quality fo life and satisfaction of older adults under end of life care? 

The PICO question of arrived at by focusing on the following population, intervention, comparison and outcome:

P: Patients under palliative care for end of life care and treatment in any setting (hospital, hospice or personal residence).

I: Different palliative treatments and interventions in to manage pain and distress, various psychological, social and spiritual interventions from caregivers.

C: Usual care practices

O: Quality of life, satisfaction from care, identifying wishes of the patient.

Database Selection

There are several databases that can be considered and used to conduct a detailed search for finding answer to PICO questions related with the field of palliative care. These databases include Medline, CINAHL, and PsycINFO. Among which Medline was selected for the current database search. This is so as Medline is the largest subset of Pubmed ensuring more updated information and citations offering results based on MeSH terms (Kelly, 2008 and Wilkins et al., 2005). This makes Medline the most relevant result-producing database even for generalises terms like old age patients, and end of life care. 

On the other hand CINAHL is considered appropriate for case studies and conducting specific search to generate qualitative evidence (Jenuwine and Floyd, 2004). This database search provides ample of sources for nursing topics but the results may not be extended to more general review of qualitative studies in other areas like palliative care (Chapman, 2009). However, there remains an overlap of results between Medlin and CINAHL.

Talking about PsycINFO, it covers psychiatric aspects of the subject or topic and may not prove to be apposite when we are studying the impact of social, and spiritual interventions also (Rogers et al., 2018 ad Moseley et al., 2009). 

This makes Medline the most appropriate database for conducting search and fining answer to the PICO question on palliative care in end of life care scenario. 

Types of Results Obtained from Search

The results based on keywords and subject headings as ‘Palliative Care’ gave too broad results that included such care in different scenarios with patients. Searching the database for palliative care and end of life experience and satisfaction failed to give any relevant results. The search did not performed as expected and therefore the keywords were changed to ‘End of Life Care’ and ‘Quality of Life’ AND ‘Satisfaction’.  It was challenging to link all the keywords in PICO question and reach the appropriate citations.

The change of keywords resulted in 570 results and most of the citations were focused on dying at a care home and experience of family members, dignity of patients and role of nursing staff in ensuring satisfaction of patients through care therapies. It was quiet difficult to reach relevant results talking of palliative care during end of life and impact of various interventions on quality of life and experience of patients.

Therefore the results from initial search were shortlisted and a new search was performed for keywords ‘end of life care’ AND ‘Impact of Interventions’. This helped to narrow the search results to 16 results making it easy to explore and understand the citations related to the PICO question.

Alteration of terms for better results

As discussed above, the keywords, headings and terms were altered several times to make the search relevant. Initially the focus was on using synonyms for the search strategy and therefore ‘palliative care’ was replaced with ‘comfort care’ and ‘end of life adults’ was replaced with ‘dying adults’. However, this strategy failed to give much of relevant citations making it necessary to focus on MeSH terms to reach appropriate results. 

In order to limit the search, Thesaurus search was also done helping to search among terms that are already indexed in Medline. Such a strategy help in getting suggested terms that narrows down the terms and provide and explanatory note providing details of their meaning in relation to Medline. Here, the medical subject heading MESH is already available that was selected to narrow down the search results and get all terms related to PICO question. 

The search for MeSH terms helped in shortlisting terms like ‘end of life care’, ‘palliative care by nurses’, ‘satisfaction from social interventions’ and ‘quality of life improving through interventions’. 

Also, the multi-field search was found to be more useful and effective as compared to a basic and advanced search on Medline. The use of Boolean logic proves to be effective in identifying some good sources of information and therefore the use of ‘AND’ helped in linking different phases and sections of PICO question. Boolean logic helped to link palliative care, end of life care, experience and satisfaction and interventions that was otherwise challenging under an advanced search strategy. This logic helped in narrowing down the search with the use of ‘AND’ as all terms must be present in each hit and at the same time it helped n widening the search with ‘OR’ to include similar terms and results. 

Appropriate Citations to answer PICO

Waller, A.; Dodd, N.; (2017). Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness. BMC Palliative Care. (16) 1. Pp. 34-45. 

Hoefman, R.; Al-Janabi H.; McCafferey, N. and Currow, D. (2015). Measuring Caregiver outcomes in palliative care: a construct validation study of two instruments for use in economic evaluations. Quality of Life Research. (24) 5. Pp. 1255-1273.

Moore KJ; Candy B; Davis S; Gola A; Harrington J; Kupeli N; Vickerstaff V; King M; Leavey G; Nazareth I; Omar RZ; Jones L; Sampson EL. (2017). Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study. BMJ Open Journal. (7) 6. Pp. 07-12.

Powis, J.; Etchells, E.; Martin, D.K. and MacRae, S.K. (2004). Can a “good death” be made better? A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients. BMC Palliative Care. (3) 1. Pp. 23-34.

Price DM; Strodtman LK; Montagnini M; Smith HM; Ghosh B. (2019).  Health professionals Perceived Concerns and Challenges in Providing Palliative and End-of-Life Care: A Qualitative Analysis. American Journal of Hospice and Palliative Medicine. (36) 4. Pp 308-315. 

Best Article from Search

The selected article is the one written by Waller et al. (2017) focused on improving hospital-based end of life care processes and outcomes. This particular article is selected as it based on a systematic review of various databases and focus on interventions and their effect on adults during the end of life care. The study provides details of results obtained in terns of satisfaction and quality of life improvement from various interventions while assessing each of these against the Effective Practice and Organization of Care methodological criteria. At the same time, the study also presents a critical analysis of these interventions identifying the need of improvement in any of such therapies or approaches for improving the experience and reducing psychological distress of patients. The mixed impact on end-of-life calls for understanding individual needs of care and offer appropriate interventions instead of generalizing these to suit every adult. The study act as a guide to select interventions that target both the patient and substitute decision maker to improve the degree of benefits and make the end-of-life care satisfactory for patients and their family members as well. 

The selected article helps in answering the PICO question by explaining the mixed results and non-generalized nature of end-of-life care interventions while delivering social, spiritual or psychological care as per individual perception of the concerned adult patient. 

Tips for Others 

The experience of this search explains the need of conducting a multi –field search instead of relying on a basic or advanced search. However, it is equally important to start with selecting the most appropriate database according to the topic or keywords to be searched. There may be instances when we start with CINHAL database as an appropriate source of nursing resources but need to look into other databases as well as end up finding the most accurate results according to PICO question in Medline or PubMed. 

Moreover, there are instances when our pre-defined search strategy does not work well and there is a need to bring a change in search strategy like depending upon Boolean approach or thesaurus search to identify the most appropriate sources of information. 

It is also important to focus on proper selection of subject headings and keywords and change these with synonyms or MeSH wherever it’s necessary to look for alternate words to reach proper results. There are a long list of search strategies that should be taken into consideration and applied as per the obtained results and the need of narrowing don or widening the area of search.