The study is aimed at evaluating the effectiveness of palliative day care in improving the quality of life for end of life patients. This arises from the rise in cases of incurable diseases and conditions in the recent past all over the world. Despite the growth in day care, there has been a failure with regard to identification of patients eminent death and hence the need to care for the patient. In order to achieve this effectively, a number of specific objectives are formulated from the core objective. The scope of the study is limited to literature review. In addition to palliative care, the study limits itself to palliative day care services and does not consider other palliative care services such as supportive care.Various terms related to palliative care are defined. This study has both a personal and professional context as far as the researcher is concerned. The study is organized into a number of chapters. The first chapter gives an overview of the entire study. Chapter two entails a critical review of relevant literature is the core research design which is used in conducting the study. A number of factors were considered in selecting the research design. These include the nature of the study, the resources available to the researcher and suitability of the method to the objectives of the study. A number of studies related to palliative day care are identified and analyzed.
Prior to conducting the study, a preliminary literature review which enables the researcher to review existing literature in the field of the study is identified. Chapter three details the method used in conducting the study. This is attained by considering a number of steps that the researcher will follow to identify and critically analyze the literature for the study. A comprehensive criterion is used in determining the literature to consider for the study. These include recency, orientation of the study, ethical considerations, language of publication. The literature selected is appraised and analyzed using previous research findings. The fourth chapter evaluates the actual access of the articles to be critically reviewed. Some of the considerations include search words and databases and research engines used. In addition, the critique and analysis methods used are analyzed whereby the articles considered are thematically analyzed. The findings of the study are evaluated in chapter four.
Through the discussion, the researcher illustrates the link which exists between the findings of the literature review and the research questions. The articles used in conducing the study are analyzed individually. Chapter six gives a comprehensive analysis of the study. This is attained through considering the various themes of the article which include needs of palliative day care patients, preferences for palliative day care services, palliative day care and social benefits, quality of palliative day care services, the link between palliative day care services and other services, palliative day care and quality of life of the patients and e economics of palliative day care. The themes are divided into major and minor themes. Each of the themes is analyzed. The last chapter entails a conclusion and recommendations. A discussion in relation to improved care, information gap, and evidence of better service and patients needs and ethical consideration are conducted. Chapter seven entails recommendations and a set of conclusions.
There has been a rise in the cases of incurable diseases and conditions in the recent past all over the world. According to Baker (2000), this has been brought about by the improvements made in the medical arena enabling patients with terminal conditions to prolong their lives. A case in point is the introduction of anti-retroviral drugs that are used to manage the deterioration of the health of patients living with HIV/AIDS. This being the fact, the number of individuals in the society living with terminal illnesses and conditions has greatly increased.
From history and research of medical problems among infants care in neonatal and pediatrics has been managed properly and the cases reduced significantly. This means that patients now survive for longer than before. The advances in medical and technological fields have evidently reduced the neonatal and gerentological death rates (Haggerty, Reid, Freeman, Starfield, Adair, Mckendry 2003). On the other hand these advances have led to more survival of patients suffering from lethal disease some of which are very lethal but there is no actual cure. This has seen the number of patients needing paediatric service increasing and thus life threatening condition is a serious problem (Hannan & Gibson, 2005). The people experiencing life-limiting and threatening sickness that can cause death or grave damages to the body deserve proper and extensive cultural reappraisal of care to be given to them( Gore, Brophy & Greenstone, 2000).
The aim would be to bring out the best outcome possible as far as the health of the individual is concerned and the quality of life regardless of the type of disease. It is very important to understand the clear difference between palliative care and the meaning of terminal care (Hanson, Tulsky & Danis 1997). Terminal care has often been mistaken for palliative yet it refers to the care that is given to the patients at the time that is very close to their death (Ringdal, Jordhøy & Kaasa 2002). This care can be given in week or few days. This clearly shows that terminal care is not same as palliative but palliative involves terminal care (Hanson, Danis & Garrett 1997). The gross misconception about these two terminologies is caused by errors that are made during creating the criteria of eligibility, the needs of such patients and the proper means to offer adequate solutions particularly for the paediatric and gerontology contexts. Just like the clinical cases, social, spiritual and psychological problems have often gotten very minimal attention (Hearn & Myers 2001).
A study across the US has shown that families would like to see their loved one treated at home and also get the opportunity to stay with them until they finally die (Hearn & Myers 2001). The patients also like staying at a place that is jovial with people like at daycares or at home. The availability of holistic support is essential and should be adequate (Lorenz et al 2004). It’s also evident that the communication that exists among professionals who attend to the palliative care patients is very limited and need improvement (Field & Cassel 1997). Probably, several cultural, affective and ethnical reasons have resulted into and affected the persistence of the short falls during patient palliative care (Latimer, Crabb, Roberts, Ewen & Roberts 1998). Furthermore it is not very easy to handle the complicated problems and this need interdisciplinary expertise intervention with realistic, effective and workable ways of dealing with the situation (Hopkinson & Hallett 1999). As is have in most cases been, when the problems seem to be more complex, the process of searching relevant solutions is delayed and doubt crops is concerning the controversies as opposed to the real needs (Keeley 2008).
This development has created an impetus for provision of end of life care to these patients (Brazil et al 2008). This is given the fact that people living with terminal illnesses and conditions deserve to be made comfortable as they approach their end of life. The pain that they experience, both physically and psychologically, need to be alleviated in order to make their last days as comfortable as possible (Collins et al 2000). The aim of end of life care as an intervention is to bring out the best outcome possible as far as the health of the individual is concerned (Kernohan, Hasson, Hutchinson& Cochrane 2006). This is regardless of the type of disease or condition that is afflicting the individual.
End of life care is the type of intervention or care that is availed to persons that are transiting through their last stages in life (Himelstein et al 2004). The individual to whom end of life care is availed is usually afflicted or living with a progressive illness or condition (Kernohan, Hasson, Hutchinson& Cochrane 2003). This is the kind of illness that incapacitates the individual as it progresses through the various stages (Dangel 2002). A case in point is a patient suffering from cancer. As the disease progresses, it impairs various aspects of the patients life, such that towards the end of their life, the patient relies wholly or to a greater extent on care provided by people around them such as doctors and family members (Finlay, Higginson, Goodwin, Cook, Edwards, Hood 2002).
There are various forms of end of life care or interventions (Low, Perry & Wilkinson 2005). These include hospice care, which availed to patients transiting through the last stages of an incurable illness or condition (Feudtner et al 2007). This is for example patients suffering from cancer which is so advanced such that it can no longer be managed effectively by medications. Another form of end of life care is supportive care. According to Benini et al (2008), this care encompasses a range of interventions that cater for the needs of various aspects of the patient’s life. This is for example the psychological support provided to the patient and their family and the medical care provided to manage their condition.
Palliative care is such end of life care intervention. According to Morrison and Meier (2004), palliative care is a medical intervention that combines different approaches to improve the health of individuals afflicted by progressive illnesses and conditions. This is for example cancer, HIV/AIDS and obstructive pulmonary diseases (Morrison & Meier 2004).
This study is going to look at the effectiveness of palliative day care in improving the quality of life for end of life patients. The study is going to assume a critical literature review format. To this end, the researcher is going to look for literature that exists in the field of palliative day care as a form of end of life care and critically analyze it. The critical analysis of the literature will be aimed at revealing what the various scholars and stakeholders in end of life care think of palliative day care and improvement of quality of life for end of life patients.
Background of the Study
Palliative day care offers a chance for patients to visit healthcare facility for the medical and nursing evaluation. From there they also get recreational therapy, companionship and a change of environment (Au et al 2006). The purpose is to assess and monitor the disease progress especially how the symptoms fair on. Emotional; support is highly encouraged at the facility. The patients get a respite while enjoyment is stimulated (McCormack 2010). Furthermore, the families of these patients get an opportunity to learn. Palliative care concentrates on the holistic care for the patients in the last or terminal period. They care works on improving physical, spiritual and psychological wellbeing of the patient (Freeman & Price 2001). This care is in most cases for the patients’ suffering from progressive disease and the purpose of this type of care by the practitioners is to offer the best quality of care which in turn would assure quality of life (Baker 2000).
The patients can at least enjoy their lives despite their conditions and this gives the care providers motivation to work harder. The services need strict multi-professional intervention to make sure that the most critical and specific needs are identified and taken care of.
Several scholars have determined that cancer is the most common of the progressive diseases that calls for palliative care as an intervention in the life of the patients. Brazil et al (2008) are of the view that cancer, in its various forms, would attack one third of a population at some point in their life. One quarter of these would end up dying from the disease (Brazil et al 2008). Palliative care is basically important to improve the quality of life that such patients would experience.
However, it is important to note that this care is not restricted to cancer patients (Au et al 2006). Other individuals who need such care include the elderly who, given their advanced age, are at risk of suffering from progressive and debilitating conditions such as arthritis.
Palliative day care is used to offer both social and physical support to patients with terminal illnesses and conditions during their end of life days (Groot et al 2005). Every individual has the inalienable right to experience a dignified life and a right death. Ethical considerations also dictate that this should be characterized by care and support from family members and health care providers. Nonetheless, this rarely happens in real life situation (Baker 2000). The reason behind this, according to medical organizations that have conducted researches, is the failure by care providers to recognize or even acknowledge signs of an impending death of a patient (Brazil et al 2006). This means that the care is not availed to the patient if the need cannot be identified.
Palliative day care is a chance for patients to improve their quality of life particularly for the health related conditions and also the general well-being of patients suffering from terminal disease conditions( Lunney, Lynn, Foley, Lipson, Guralnik 2003). Palliative day care brings a service to the sick over a range of conditions even going beyond health and social experiences. The facilities offer social environment for allowing therapeutic activity to take place (Au et al 2006). With these services in place, there are several advantages that come with such comprehensive care to the patients who attend the palliative day care as opposed to those who do not attend such care (Mularski et al 2007).
Objectives of the Study
The major objective of this critical literature review study is to determine the effectiveness of palliative day care in improving the quality of life for end of life care patients.
By addressing the specific objectives, the researcher would have effectively attained the major objective of this study. The specific objectives are as listed below:
- Assess individual preferences for palliative care
- Assess the influence of culture on individual preferences for palliative care
- Assess the impact of palliative care on the quality of the individual’s life
- Assess factors that affect the effectiveness of palliative care in improving the quality of life for the individual
- Assess the current status of palliative day care in the field of end of life care provision
By conducting the envisaged critical literature review, the researcher will be aiming at answering one research question. This is:
What is the effectiveness of palliative day care in improving the quality of life for end of life care patients?
Definition of Terms
Palliative care: medical intervention that combines different approaches to achieve improved health-related outcome to the patients suffering from progressive illness like cancers, HIV or obstructive pulmonary disease (Morrison & Meier 2004, p. 2584). For this research, Palliative Care will be used to refer to the provision of care aimed at improving the quality of life of patients or individuals who are faced with life threatening illnesses and conditions.
End of Life: this is the period of time in a person’s life that is characterized by disability or illness that becomes progressive (life threatening). The disease or condition usually ends in eventual demise (Benini et al, 2008, p. 78).
End of Life Care: This is the kind of care that is given to individuals when they are going through their last stages of their life. Hospice care, comfort care and palliative care and sometimes supportive care are some of the phrases adopted to describe such situations (Himelstein et al 2004, p. 1754). “However, in an attempt to turn away misunderstanding, the researcher used “end of life care” where all the other terms can be utilized to convey the same meaning.
Hospice Care: this is used to conceptualize provision of care to patients who are progressing through the last stages of an incurable illness or a condition that can no longer be treated and it’s in the advanced stages( Gomm, Hobson, Murtagh & Caress 2010). The aim is to make the final days of the individual’s life more comfortable by way of relieving their pain and a host of other symptoms (Jemal et al, 2002).
Supportive Care: It is a term used to demote to a wide range of services, encompassing hospice and palliative care. It can take the form of medical car and covers the aspect of care including physical, social as well as psychological wellbeing like counseling services to these patients (Morrison & Meier 2004, p. 2584). The aim is to make the last days of the individual as comfortable as possible before the demise.
Terminal Care: This care is also provided for a person who is afflicted by a life threatening or terminal illness. This is especially when they are in the final stages of such illnesses, the end phase of their life (Jemal et al, 2002).
Good Death: this describe death that not with any type of avoidable distress and pain for the patient and even the family. It’s presumed to be in accordance to the wishes of everyone, that is, the family and the patient as well as the care giver.
Simultaneous care: this is the situation when the patient is given palliative care and at the same time put on clinical trial for a curative medication (Burns et al 2003, p. 548).
Chronic pain: this is the type of pain perception that is cause by chronic diseases or injuries making it to persist for a very long time regardless of attempts to treat or manage the condition and the underlying cause. Cancers, arthritis and serous injuries are major causes of such pain (Benini et al, 2008, p. 81).
Acute Pain: this is the type of pain that is intense, short-lived and it’s often caused by mild injury, sudden occurrence of disease or other health related condition (Langley-Evans1997).
It is imperative to note in this report the terms defined above may have other definitions and applications in varying contexts, but will be applied herein according to the way they are defined above (Jemal et al, 2002). The researcher acknowledges this fact, and effort has only been made to give their definitions as used in this paper.
Significance of the Study
The findings of this study will go a long way in improving the quality of care provided for end of life care patients, especially those in need of palliative day care services. The following are some of the uses of the findings in improving palliative care:
- The findings of this study will help stakeholders identify challenges that affect quality of palliative care
- The findings of this study will further help stakeholders such as care providers come up with strategies that can be used to avert challenges to quality palliative care and also strategies that can mitigate the effects of the challenges
- The findings of this study will help the stakeholders in palliative care and other end of life care services in extension to come up with strategies that can improve the delivery and quality of the services
- The study will also identify areas that future researchers in the field of end of life care and especially palliative day care can conduct their studies
Scope and Limitations of the Study
- The study will limit itself to critical review of literature that already exists in the field of palliative day care. Primary sources of data such as interviews and observations will not be conducted.
- The literature review will be limited to the effectiveness of palliative day care in improving quality of life for end of life patients. Other aspects of palliative day care such as health care facilities offering the service will not be focused on, or where analyzed, such aspects will occupy peripheral positions.
- The literature review will have as its central focus the palliative day care. Other end of life care services such as supportive care will not be focused on.
As earlier indicated in this paper, this study will take the form of a critical literature review. This means that the researcher will access literature that touches on palliative day care and analyze the same critically with the intention of finding out the effectiveness of palliative day care in improving the quality of life for end of life care patients.
The researcher will come up with a Boolean table that identifies the combination of terms that will be used to search for articles which will be critically reviewed. The articles will be sourced from various data banks. These include online data bases such as JSTOR. For online articles, the researcher will use the search terms that have been identified to access these articles using various search engines.
The articles so identified will be taken through a preliminary filtering phase. This is where the researcher will analyze the articles and select those that are relevant to the study. The articles so selected will be taken through a thematic analysis so that the researcher can identify the themes running through these articles. It is these themes that will be reviewed to answer the research questions identified.
Context of the Study
This study has both a personal and professional context as far as the researcher is concerned. As a *client inserts their specialization or profession here* (student), the researcher has had the opportunity to interact with patients that are suffering from advanced conditions such as cancer and HIV/AIDS. The researcher have noted that those patients receiving palliative day care such as provision of medical care live a much more comfortable life. For example, the researcher noted that they are admitted to the emergency wards less often. This discovery piqued the researcher’s curiosity. They were interested in conducting a scientific investigation that will reveal the effectiveness that palliative day care had on the quality of life for end of life care patients. This is how the current study came into being.
Format of the Study
The study will have several chapters. This includes an introduction chapter that will give the reader an overview of the whole study. This will be followed by a preliminary literature review where the researcher will review literature that exists in the field of the study. Chapter three will touch on methodology, the steps that the researcher will follow to identify and critically analyze the literature for the study. The fourth chapter will touch on the actual access of the articles to be critically reviewed. This will be followed by an analysis chapter. This will thematically analyze the articles. A discussion chapter will follow, which will dwell on the link between the findings of the literature review and the research questions. The last chapter will be conclusion and recommendations. This will sum up the whole study and recommend areas for further research.
This chapter introduced the reader to the critical literature review. An overview of the study was provided, including the objectives of the study and research questions. The following chapter will dwell on preliminary literature review. This is not the review of the articles identified for this study; rather, it is a review of literature that exists in the field of palliative care and end of life care in general.
In chapter two, the researcher provided the reader with a preliminary literature review for this study. The review was on literature that exists in the field of palliative care and end of life care and patients. Findings of several studies in this field were presented, together with the highlight of the link between these studies and the current research. The aim was to contextualize the current study within this field. This is by identifying knowledge gaps that can be field by the findings of this study. It is important to note that the researcher provided just a preliminary literature. The critical literature review for the articles selected for this study will be provided later in the paper.
In this chapter, the researcher is going to highlight the steps that will be taken in selecting the articles and papers that will be critically reviewed for the study. Among the areas that will be covered include the definition of what critical literature review is and justifications as to why the researcher selected it for this study. The purpose of critical literature review as a research methodology will also be highlighted. This is together with the benefits and weaknesses of this methodology. The researcher will also provide information on the process of searching for literature to be reviewed. This includes the inclusion and exclusion criteria that will be used together with the selected search terms and keywords. The methods that are used in critically reviewing literature will also be provided in this chapter. Finally, the researcher will provided information on ethical considerations that exists hen one is using the findings of research carried out by other people to conduct their own study.
Literature Review: A General Overview
Many scholars conceptualize the term literature review variously. The definitions by various scholars are informed by their (scholars’) orientations and the purpose of their studies. According to Green et al (2006), literature review can be conceptualized as a body of text intended at reviewing the salient features and points of existing body of knowledge. This includes findings of studies that have already been conducted in the field together with methodological and theoretical frameworks in a given field. For example, a literature review in the case of the current study will include a review of critical facts and features of studies, methodologies and theoretical underpinnings in the field of palliative day care.
There is one central feature that differentiates literature review from other research processes. This is the fact that it is basically a secondary source of information (Taylor 2009). In this light, it is pertinent to note that literature reviews are not, under any circumstance, sources of new knowledge in the field. All they do is analyze and organize the findings of other studies or for that matter, analyze and organize knowledge that already exists (Dellinger 2005).
To put it otherwise, there is a great difference between literature review and a conventional academic research. This is given the fact that the main purpose of the latter is to articulate and develop a new and original argument (Woolliams et al 2009). Literature review is usually a part of an academic research paper. It is used to bring the reader up to date with developments in the field within which the current study is being conducted.
For the purpose of this study, the researcher will adopt the definition of literature review that is given by Anson and Schwegler (2000). The two conceptualize literature review as the process of discussing and analyzing published works and information that is to be found within a particular discipline.
There are several formats that can be adopted by a researcher when carrying out a literature in a given field. According to Cooper (1988), the researcher can review the whole literature within the field or, in some cases, adopt criterion that will be followed in reviewing the same. For example, the researcher may opt to review literature that covers a certain period of time or a particular dimension of the topic under study (Cooper 1988).
The major goal of literature review in any research has already been tentatively indicated elsewhere in this paper. For the purpose of this study, the researcher will use literature review to summarize, synthesize and analyze the arguments and positions that have been adopted by other scholars within the field (Kabilan 2003).
According to Anson and Schwegler (2000), there are several functions that a researcher may perform when conducting a literature review. The researcher may opt to address the controversies raised by the literature, in essence addressing the contentious issues that the literature elicits in the field it is found within. The researcher may also address the consistency or lack of it thereof between the literature been reviewed and other existing knowledge in the field. The source of inconsistencies and how they have been addressed by stakeholders in that particular field are addressed here (Woolliams et al 2009).
The inadequacies of the literature may also be addressed during the literature review. This includes identifications of the goals of the study and determination of the extent to which the findings of the study met those goals. The reason for the inadequacies and how they have been addressed is also highlighted in literature review (Taylor 2009).
Critical Literature Review: An Overview
The preceding section highlighted the concept of literature review in general. Having done this, it is now important to look at critical literature review and identify the differences between the two.
Kabilan (2003) provides a difference between a literature reviews in general and critical literature review. This scholar is of the view that critical literature review is basically a literature review but which takes place at an advanced level. The researcher goes beyond mere description of the sources and articles consulted by the researcher for the study (Hart 2004).
For a literature review to be considered as critical in nature, the researcher must analyze in depth the scope of the literature in relation to the study been conducted currently (Green et al 2006). For example, the researcher should critically analyze the subject matter of the literature and how well it addresses the topic within which it was conducted.
It is important to note when conducting a critical literature review as a research method, the researcher already has a tentative subject that they wish to address. For example, the current study wishes to address how palliative day care improves the quality of life for end of life care patients. To this end, when conducting a critical literature review, the researcher is expected to critically analyze the relevance of the articles identified or been reviewed to this topic.
To clearly understand critical literature review as a concept, it is important to first have a working definition of what being critical means. According to Woolliams et al (2009), being critical can be conceptualized as the “careful selection of sources, thoughtful analysis of the sources and questioning of these sources” (3). According to them, being critical is being questioning and refusing to take things, ideas, concepts and arguments at face value (Hart 2004). As such, the researcher, when carrying out critical literature review, must adopt a stance of calculated doubtfulness.
A social scientist carrying out critical literature review can be likened to a physical scientist in the laboratory. The social scientist does not look at the articles been reviewed superficially. To the contrary, they assume a mien similar to that of a physical scientist looking at a specimen under a microscope. Only that in the case of the social scientist, the microscope is their mind’s eye which is magnified by the doubtful nature with which the articles are to be reviewed.
The researcher, when carrying out a critical literature review, does compare the points raised by the article with those of other scholars in the field (Danson 2007). The aim is to find out whether the point of view of the author of the article been reviewed is supported or refuted by others in the field. The strength of the article in the eyes of the critics is also established.
Critical Literature Review as a Research Methodology
As earlier noted, a researcher may make use of literature review as a methodology to conduct their own study. Critical literature review as a research methodology, according to Kabilan (2003), involves the researcher critically analyzing the findings of other studies in the field and in the process identifying their strengths and weaknesses.
The first step of the critical literature review is to formulate a research topic and a research hypothesis. The researcher should be clear from the start that they are not going to consult primary sources of data such as interviews. Rather, they will use the findings of other researchers in the field. Just like in any other academic research, research questions and objectives are also identified (Randolf 2009).
The next step is to identify the orientation of the articles that the researcher wants to critically review. It is important to note that there are thousands of articles that have been written within the particular field. As such, it is important for the researcher to come up with a criteria set to select the articles that they want to review. It is important for the researcher to come up with a large number of articles than they want to review. This is given that in the vetting process, some articles will be dropped from the list.
The researcher accesses the articles from the databases by coming up with search terms and key words that are keyed in the databases. The articles accessed are then vetted using criteria such as their relevance to the topic under study, their recency and the credibility of the findings (Green et al 2006).
There are several strengths and weaknesses attached to critical literature review as a research methodology. This is especially so given the fact that the researcher is using the findings of other people’s studies, and as such, has no control over the conduction of the primary studies they are consulting. These strengths and weaknesses, together with other salient features of critical literature review, will be addressed later in the paper.
Justifications for Using Critical Literature Review for this Study
According to Randolf (2004), there are many research methods at the disposal of the researcher when conducting a new study. However, several factors inform the selection of one methodology amongst the many to conduct the study. This is given the fact that it is not possible to combine all the methods to collect data for one study. As such, a selection of one or two methodologies is made for a particular research. The factors considered in the selection include the nature of the study, the resources available to the researcher and suitability of the method to the objectives of the study. For example, a study aimed at collecting primary data may opt for a method such as face to face interview as opposed to review of literature.
This study made use of critical literature review to collect data and information needed. Several factors informed the researcher’s selection of this methodology in the midst of many.
One factor informing the section of this methodology was the aims and objectives of the study. The researcher was interested at appraising and reviewing knowledge that already exists in the field of palliative day care and quality of life for end of life patients. According to Taylor (2009), knowledge that exists in any given field is archived in databases in form of literature. As such, to appraise this knowledge, the researcher needed to review the literature in the field. It is important to note that the literature review for this study was not a part of a research paper; rather, the whole of the research paper revolved around it. As such, it was mandatory for the researcher to go beyond mere review of the literature and review it critically (Kabilan 2003).
To enhance the credibility of the study, the researcher needed to probe and question the knowledge presented in this field by past scholars. This could only be done through a critical literature review.
This study was conducted using a humble budget. As such, the researcher was limited in terms of resources. Primary data collection methods such as interviews call for a relatively larger investment in terms of financial and other resources. Given the limitations of the researcher in terms of these resources, they opted for a critical literature review which is relatively cheaper. This is given that the entire researcher needed to do was organize findings of studies that have already been conducted in the field.
Time limitation is another factor that created an impetus for a critical literature review. Literature review takes less time than other primary sources of data. For example, to collect data through observation, the researcher needs to wait until the optimal conditions for observations are attained. This is different in literature review. The researcher can conduct the review at any time. This means that relatively little time is spent on literature review than on other methods such as interviews and observations.
Searching for Literature in Critical Literature Review
There are several steps that have to be followed before the literature to be reviewed is accessed. The researcher has to come up with search terms and a list of databases among other things.
It is important to note that the actual searching of the literature for review is one of the most important steps in critical literature review. In any given field, there are many articles archived in the databases making up the literature in the field. It is this literature, or rather, these articles that the researcher aims at critically reviewing.
However, it is not all of the articles in any given field that are relevant to the topic being studied. This being the case, the researcher has to come up with criteria to be used when selecting articles that are relevant to the study, the articles that will be critically reviewed (Randolf 2009). The selection of the articles to be reviewed should also be conducted in a critical manner. Relevant articles are separated from those that are not relevant, picking the former and discarding the latter (Kabilan 2003).
It is important to note that selection of literature or articles to be critically reviewed should be carried out in a methodical manner. This is given the fact that even those relevant articles that have been selected have to be subjected to rigorous vetting to select those that are very important and very relevant to the current study. This is especially so considering that the researcher has a set number of articles that they wish to critically review.
It is as a result of this necessity to vet articles that inclusion and exclusion criteria come into play.
As the name implies, inclusion criteria are standards that are set and which each article must meet for it to be considered for critical literature review (Kabilan 2003). In other words, these are minimum requirements for an article that is been critically analyzed. There are instances where the researcher requires for all the articles to meet all the inclusion criteria, while in other instances, an article meeting one or at least a specified number of the criteria I considered for literature review. The requirements and standards set vary from one study to the other. Following is a list of some of inclusion criteria:
This criterion takes into consideration the date of publication of the article. The nature of the study dictates the time period within which the researcher selects articles (Cooper 1988). For example, a critical literature review interested in a certain event in history may select or include articles that cover this period alone. Again, a historical or archeological literature review may be interested in antiquated literature as opposed to new literature.
Other studies, for example scientific inquiries, may only consider reviewing very recent literature and ignoring antiquated ones. This is given the fact that recent literature is bound to capture recent developments in the field.
Orientation of the Study
Different studies in a particular field have different orientations depending on the issues that their researcher intended to address. For example, there are peer reviewed articles, other articles based on literature review and articles based on primary research such as interviews. The interest of the researcher conducting critical literature review together with the objectives of the study will inform the articles selected for review. For example, the researcher may opt to include in their critical literature review only those articles that have been peer reviewed Scottish Intercollegiate Guidelines Network 2009).
Ethical Considerations as an Inclusion Criteria
Ethical considerations are perhaps one of the most important tenets in any form of academic research. This is especially for a critical literature review. This is given that the researcher in a critical literature review is making use of findings of studies conducted by other researchers in the field. It is important to ensure that the articles been reviewed were written in an ethical manner (Hart 2004). This is because ethical considerations in an article been reviewed or lack of it thereof affects the ethicality of the critical literature review. This is because a critical literature review that uses articles detailing studies that were conducted unethically will as a result become unethical itself. This being the case, the researcher will include in their critical literature review only those articles that represent studies that were conducted ethically. The ethicality of an article can be deduced from peer reviews and commentaries of other scholars regarding the article among other processes (Anson and Schwegler 2000).
Language of Publication
The researcher is likely to come across articles written in different languages as they are searching for literature to review. This being the case, the researcher then selects articles that are written in a language that they can understand (Kabilan 2003). The language of the target audience is also taken into consideration. This is given the fact that the audience may need to access the articles that have been critically reviewed themselves. If the target audience is basically of English orientation, the researcher may not select articles written in Chinese because they themselves can understand the language.
The above are just some of the criteria set by a researcher hen selecting articles to critically review. Other criteria include the qualifications of the article’s author, whereby only those articles that are published by qualified writers are considered for inclusion. The depth and breadth of the article, or in essence the scope and limitations of the same, are also put into consideration. This is because the researcher may be interested in articles that are analytical and have content that provides an in depth insight (Scottish Intercollegiate Guidelines Network 2009).
The inclusion and exclusion criteria in the selection of articles are related; they are two sides of the same coin (Hart 2004). When an article fails to meet the inclusion criteria, it then means that it is automatically excluded from the literature review. For example, when an article is published in French and the researcher wanted articles in English, then this article is automatically excluded. Language of the article becomes an exclusion criterion in this case.
Search Terms and Key Words
Findings of studies conducted in a given field are published in journals and other articles. These are then archived in databases and form the literature and knowledge base in that field (Dellinger 2005). When a researcher or any other interested party wants to review literature in this field, they are obligated to access these databases and retrieve the articles they are interested in (Dellinger 2005).
According to Kabilan (2003), there are as many articles in a particular field as there are studies conducted there. As such, it becomes paramount for the researcher to come up with strategies aimed at accessing the articles that are relevant to their study.
This is achieved by having the researcher enter combination of words and term into the data base, which may either be electronic or otherwise. The combination is aimed at making the researcher access the articles from the database. This combination of words and terms, according to Danson (2007), is what is referred to as search terms or key words.
The articles archived in different databases are what the researcher conducting a critical literature review is interested in. different databases organize different articles variously. Different databases also contain different types of articles with a particular orientation (Randolf 2009). For example, articles about medicine or palliative care may be found in a different database from those addressing archeological findings. This being the case, it becomes important for the researcher to identify the databases that are likely to contain the articles that are relevant to their study.
There are different databases in existence. These may be found online or in library catalogues. These include JSTOR, BioMed, Google and such others. The researcher may select articles from a combination of databases or utilize articles exclusively drawn from one database.
Critical Appraisal of Literature: Critiquing Methods
Now that articles to be critiqued have been accessed and selected, it is now time to critically appraise them. There are various critiquing methodologies at the disposal of the researcher. The orientation of the article to be critiqued is the one that usually informs the method that will be adopted by the researcher (Cooper 1988). The following are some of the methods that are used to critique articles and literature written by other people:
Goal Critiquing Method
In this method, goals and objectives for the critical literature review are identified. The researcher will then be informed by these goals and objectives when reviewing the literature identified (Randolf 2009). For example, the researcher may set an objective of reviewing the article by identifying how well it addresses controversies in the field, or how well it augurs with other studies in the particular field (Cooper 1988).
The researcher may criticize articles with the aim of establishing whether they support or refute the perspectives and beliefs held by the researcher (Kabilan 2003). For example, a researcher may be convinced that communism leads to a better life than does capitalism. When critiquing the articles, they will be aiming at establishing whether the findings of the studies they are critiquing support or refute this position.
Focus Critiquing Method
In this method, the researcher identifies the focus of the study or article they are critiquing, and then use the same to analyze the articles (Cooper 1988). For example, the researcher may critique the articles based on how well the findings relate to the current study.
Critical Literature Review as a Methodology and Ethical Considerations
Dellinger (2005) is of the view that using the works of other people to conduct a study has many ethical considerations riding on it. For example, it is paramount for the researcher to acknowledge the work of other people when using it in their study. This is done through citations and other methods that inform the target audience that the researcher is using the work of other people. The source of information should always be acknowledged.
It is also important for the researcher to interpret the findings and arguments of other people correctly (Dellinger 2005). As much as they are criticizing the works of others, it is important to make sure that they are criticizing the correct sentiments of the authors. The researcher should desist from misinterpreting the arguments of the article’s author and then going ahead and criticizing these misinterpretations.
Finally, the researcher should ensure that the findings they are using to conduct their own studies were collected ethically (Taylor 2009). Findings from studies that have been known to have resulted in abuse of animal or human rights should not be used.
Ways of Analyzing, Reworking and Using Previous Research Findings
As earlier indicated, critical literature review is quiet different from other academic research methods. This is given the fact that it makes use o findings of other studies to achieve its research objectives and purposes.
Thematic analysis, according to Taylor (2009), is one of the methods used hen analyzing works done by other people. This involves identifying common themes in different articles then presenting these themes to the target audience. The researcher may identify, for example, five themes when critiquing ten articles (Edmonds, Karlsen, Khan & Addington-Hall 2001). They then identify the number of articles that share the same themes, or, in other words, the number of articles that address one theme. The ideas and arguments of the authors are effectively mapped by the researcher using this method.
When critiquing the works of others, the researcher should make sure that the target audience knows whether what they are reading is the idea of the researcher or it is the ideas of other people (Randolf 2009). The researcher may use direct quotes or paraphrasing of the ideas of other people. This is important as it reduces cases of plagiarism, a serious offence in any research.
This chapter provided the reader with an overview of critical literature review as a research methodology. Definitions of literature review, justifications of the same in this study and ethical considerations were some of the items addressed in this chapter.
The next chapter will provide the reader with an overview of the steps that were followed by the researcher in identifying and critiquing the articles for this study.
In the last chapter, the researcher introduced the reader to critical literature as the methodology that will be used to collect data for this study. An overview of critical literature review as a research methodology was given, including the importance of search terms, search engines and Boolean table. Also, the researcher highlighted the weaknesses and strengths of critical literature review, ethical considerations in addition to other aspects of critical literature review.
In the previous chapter, the importance of search words and databases in mining data was highlighted. In this chapter, the key search words and terms that were used and the databases that were selected, together with the justification of the same, will be provided. The inclusion and exclusion criteria, critique methods employed and their accompanying justifications will be provided also.
Search Words and Databases
This study sought to critically analyze literature pertaining to effectiveness of palliative day care in improving the quality of life for end of life patients. The search terms that the researcher selected mirrored this requirement. The Boolean table below presents the search terms used:
Table 4.1: Boolean Search Table.
|Palliative day care||And||Effectiveness||And||End of life patients|
|Palliative care||And||Quality of life||And||End of life patients|
|Palliative care||And||End of life||And||Challenges|
|Quality of life||And||Improving||And||End of life patients|
The search terms that were used were aimed at providing articles to the researcher that are relevant to the topic. The search resulted to a total of 24423 articles. But the total number of articles needed for critical review was 122. This was to be made up of 33 systematic reviews on the topic and a further 89 touching on intervention reports.
The articles were accessed from various databases using various search engines. The databases were accessed from the university’s library and other libraries. The table below depicts this development:
Table 4.2: Search Engines.
|Search Engine (Database)||No. of Articles|
|Systematic Review||Intervention Report|
|Total Via Search Engines||28||72|
|Snow Ball Finds||5||17|
To select the search engines and databases, the researcher considered their relevancy to this topic. A total of five search engines were used as indicated above. As for the snow ball findings, these five articles were found referenced on the articles accessed from the data bases. The researcher reviewed them and found them to be relevant.
Inclusion and Exclusion Criteria
Since there were many research papers done about palliative day care, the researcher had to create a criterion to narrow down to few papers for study (Ciemins et al 2007). The inclusion criteria are used for determining the articles to be reviewed. The following criteria were set:
The English language has become a de facto language for use in research writing and the target audience understands it well. For this reason, papers that were included in the study were only those ones written in English.
Date of Publication
Usually, current information in research is very important and this is why time limit is a concern. This is set particularly when the researcher feels that there have been a lot of recent developments that are very critical in the determination of the quality of the study (Douglas et al 2000). It’s likely that the recent articles will include latest advances in their discussion or conclusion about that subject. For this reason, the researcher included papers that were written from January 1994 to May 2008. Peer reviewers advised that even the latest papers on 2010 would be included.
Topic of Study
The topic of study was palliative care hence the articles to be reviewed were those that addressed palliation (Douglas et al 2000). The researcher was interested in studies that dealt with how palliative care improves quality of life of the patients with progressive illness. The researcher asked themselves some important questions that helped determine which articles would be included in the study (Ciemins et al 2007). The criteria here were that the articles had to utilize various intervention of dealing with progressive illness in palliative care.
The criteria here are similar to that of inclusion since when a particular article has been considered for inclusion in a systematic review, it means that it has met the criteria of inclusion. Those that fail to meet the criteria definitely fall on the exclusion criteria (Ciemins et al 2007). In this case, the articles that were not written in English were automatically excluded because the researcher could not understand the other languages. Lack of understanding can distort information gravely. Also, the articles that did not address palliation were eliminated. Furthermore those that addressed palliative care but did not cover various intervention techniques were excluded. Those dealing with single means of care were also excluded.
Critique Methods Used
The researcher used several critique methods that were identified by Cooper (1988). The articles selected were criticized according to their focus and goal perspective. To this end, the researcher was interested more on the findings of the studies highlighted by the articles and how they related to their topic. This is together with the goals that the studies had set for themselves, and how far they were able to attain those goals. This is in addition to how the goals of the articles relate with the objectives of this study.
Thematic analysis method was used in this study. The researcher was more interested on the themes that were covered by the articles identified. Therefore, analysis of those themes was the best way to discern the relevancy of the article.
Thematic analysis is a method whereby the researcher analyses, as the name suggests, the themes of the articles. Articles usually have a central theme around which they are organized. The researcher identifies these themes and clusters those articles that address similar themes together. It is important to note that some articles address more than one theme. In this case, the researcher may be forced to include one article in various thematic clusters identified. For example, one article may address the theme of end of life care preference while at the same time it addresses the theme of cultural influence of the same. In this case, the researcher will classify the article into these clusters. Several methods are used when doing a thematic analysis. A researcher may use a mind diagram, a spider web diagram and a myriad of others to organize the themes of the articles.
In chapter four, the reader was taken through the steps that were followed in selecting the articles to be critically reviewed for this study. The search terms used, the Boolean table and the databases accessed were some of the highlights for this chapter.
In this chapter, the researcher is going to take the reader through a summary of the articles that were identified for the study. This chapter will include critical analysis of the articles, whereby weaknesses and strengths of the same will be highlighted.
Composition of the Articles Accessed
The researcher critically reviewed 10 articles. The table below depicts the combination of these articles:
Table 5.1: Combination of Articles.
|Type of Article||Number|
The articles were selected given the fact that they met the criteria identified by the researcher for this study. The criteria included recency, relevance, and credibility of the authors among others. A summary of the critiques follows below:
A Summary of the Article Critiques
This section will provide a summary of the critique for the ten articles identified for this study. The summary will cover strengths and weaknesses of the paper, or in essence, their quality.
A New Approach to Eliciting Patients’ Preferences for Palliative Day Care: The Choice Experiment Method, Douglas Hannah-Rose, Normand C. E., Higginson I. J., and Goodwin D. M., 2005.
This article presents the findings of a study conducted by these four scholars in England. The study aimed at finding out the combination of aspects that influences the choice for palliative day care in patients. It was conducted in four centers in England, using 79 respondents.
The scholars found that most patients valued specialist therapies, and this is the single aspect of palliative day care that informed preference for palliative care to a larger extent. Further, the scholars found that those patients who were aged 65 years and below exhibited a stronger preference for specialized therapies as opposed to those patients who were sixty five and above. The scholars put this down to the fact that younger patients take a more active role in the provision of care than their older counterparts. The younger patients also may have different needs from those of older patients.
One attribute that made this article qualify for this study is the affiliation of the scholars. The four are drawn from different departments in three different institutions of higher learning. These are London School of Hygiene and Tropical Medicine, Trinity College (Dublin) and Department of Palliative Care and Policy in King’s and St. Thomas’ Medical School in London. All of the scholars also have PhD’s in different fields related to palliative day care.
The fact that this article represents research carried out by four different individuals is indicative of the fact that it is a credit worthy article. This is given that the four scholars brought different perspectives into the article, making it more objective.
However, there are some weaknesses associated with this article. The research was carried out in England alone, and as such, without support from other studies, the findings can not be generalized to apply to other countries such as America. The article also looked at the interplay of six different aspects that influence selection for palliative day care. It fails to depict the influence of each of these aspects as stand alone phenomena.
A Qualitative Evaluation of the Impact of Palliative Care Day Services: The Experiences of Patients, Informal Carers, Day Unit Managers and Volunteer Staff, Low J., Perry R and Wilkinson, S., 2005.
This article also represents the findings of an experiment conducted in four palliative care day units in the United Kingdom. The objective of this study was to examine the experiences patients and care givers in palliative care day centers in the country. The study also aimed at finding out the effects that these services had on the life of the participants.
The scholars found that the patients derived benefits from the support provided by the professional care providers. They also benefited psychologically from the social support they received from their fellow patients. This study also found that the patients preferred services from palliative care day centers as opposed to those from main stream hospitals. This is given the fact that the services availed here are specialized. These findings are supported from those of Douglas et al presented in the article above, where patients expressed support for specialized therapies in day care centers.
A major strength of this article is the affiliation of the authors. They are all affiliated to Marie Curie Palliative Care R & D Unit, Royal Free and University College Medical School in London. The study also addresses the experiences of other stakeholders in palliative day care apart from the patients. The experiences of the managers, volunteer staff and carers give this article a wide scope.
However, the article limits itself to the experiences of stakeholders that are to be found within the walls of a palliative care day center. The experiences of other stakeholders such as the patients’ family members, which are also important, are not to be found here.
Assessing Structure, Process and Outcome in Palliative Day Care: A Pilot Study for a Multi-Centre Trial, Douglas H R, Higginson I J, Myers K and Normand C, 2000.
This article is a representation of the findings of a study conducted to fin out the relationship between structure and processes of palliative day care. The study also aimed at finding out how service outcomes in a palliative day care could be assessed. Observations were carried out by these scholars in five centers in the United Kingdom.
The scholars found that the needs of patients benefiting from palliative day care are not uniform or universal. Rather, they vary from one patient to the other, and in addition, the needs and capacity of a palliative day care patient to derive benefits from a given aspect of the service fluctuates from time to time. The scholars also found that the managers can not willingly control factors that influence the quality of services provided and the resources at the disposal of the center.
The scholars carried out this study on the behest of the Palliative Day Care Study Group. The study was funded by NHSE London Region. The affiliation of the scholars to these institutions is an indication of the fact that this is a peer reviewed article, and as such, an article that is highly credible.
However, just like in the case of Douglas et al (2005) study in the first article above, this study focused on palliative day care centers in the United Kingdom. As a result, the findings can not be generalized to reflect the case in other developed nations such as Canada.
Does a Social Model of Hospice Day Care Affect Advanced Cancer Patients’ Use of Other Health and Social Services? A Prospective Quasi-Experimental Trial, Higginson I J, Gao W., Amesbury B., and Normand C, 2009.
As the title of the article indicates, this is a prospective quasi experimental trial that aimed at finding out the effect of hospice day care on the utilization of health and other social services in cancer patients. The scholars used control groups to conduct the study, and hence the quasi experimental nature of the study.
The study found that patients making use of hospice day care also make use of higher levels of services, both health and otherwise, than those who have not started hospice care or those receiving other forms of care services. Hospice day care patients also have higher levels of palliative need than the others. In conclusion, the scholars are of the view that the provision of hospice day care supplements other services such as palliative day care. This service also has little impact on other services provided by the community to these patients, such as counseling.
The accuracy of the article is emphasized by the use of control groups, making the findings more credible. The study also focuses on one particular class of patients; those with cancer. As such, the scholars were able to carry out an in-depth study on this one aspect.
However, this was also the major weakness of this article. It tended to focus on one group of patients, only those afflicted by cancer. The results can not be confidently generalized to apply ton other patients in need of palliative care, for example the elderly. The study also focuses on patients alone, leaving out the views of other significant stakeholders such as the family members and the care providers. This limits the scope of the article.
Effectiveness of Palliative Day Care in Improving Pain, Symptom Control and Quality of Life, Goodwin D M, Higginson I J., Myers K., Douglas H R and Normand C E, 2003.
This article addresses the study carried out by these scholars to find out the effectiveness of palliative day care in improving several attributes of the patients’ life. These included pain, symptom control and quality of life. Like in the study conducted by Higginson et al (2009) and highlighted above (4), this article also depicts a study that used a control group.
The study was conducted within a period of three months. According to these scholars, the patients in the experimental group (attending palliative day care centers) and those in the control group (receiving other services such as inpatient and home based care but not palliative day care) maintained overall health related quality of life. It was found that palliative care does not improve health related quality of life for the patients.
The findings of this study make this article to be very provocative. Many health care providers, patients, family members and other stakeholders have the tendency to believe that palliative day care improves the overall quality of life for the patient. But this study refutes this, indicating that while other aspects of the patient’s life (for example sociological as indicated Joe et al  above) may be improved by palliative day care, health related aspects such as pain and symptom control are not significantly improved. This provocative nature is one of the major strengths of this article.
However, this article is made weak by the fact that the scholars had no base line data for the study. The scholars only studied those patients already referred to palliative care, institutional based or otherwise. They did not have data on the quality of life for these patients before they started accessing these services. This observation makes the findings of the study questionable, eroding the standing of the article significantly.
Palliative Day Care: What does it Cost to Run a Centre and Does Attendance Affect use of Other Services? Douglas H-R, Normand C E, Higginson IJ and Goodwin D M, 2003.
This article details the findings of a research study aimed at gauging the cost of running a palliative day care. The scholars also aimed at assessing the patterns of resource utilization emanating from attendance in these centers.
Despite the fact that the major aim of this critical review is to find out the effects of palliative day care in the quality of life of the patients, the researcher found this article pertinent even though it addresses the economical aspect of palliative day care. This is given the fact the cost of running a palliative day care affects the quality of services provided and in extension, quality of life for the patients.
According to this article, it was found that it costs around 54 pounds per day to cater for one patient in a palliative day care in the United Kingdom. When unpaid for resources such as halls and fields are included, this cost rises to about 75 pounds.
This article is an insightful report on an aspect of palliative day care that scholars, especially in the medical fraternity, pay little attention to. The connection between cost of running of a palliative day care centre, the quality of services provided and the quality of life for the patients is provided by this article.
One major shortcoming for this article is that it represents a study that, as earlier indicated, concentrates more on economics of palliative day care as opposed to the quality of services provided. Deductions and synthesis is needed to marry these findings to quality of life for palliative day care patients. The study also fails to provide a comprehensive economic evaluation for the palliative day care centers in the United Kingdom. This is given the fact that the scholars failed to factor in the fact that facilities in palliative day care centers are shred with other facets of the centers, such as in patients, to cut down on costs.
Quality of Life, Day Care Hospice Needs and Satisfaction of Community-Dwelling Patients with Advanced Cancer and their Care Givers in Japan, Miyashita et al, 2008.
These Japanese scholars had three objectives in carrying out this ethnographic study as illustrated by this article. They intended to analyze the quality of life of community dwelling patients afflicted with advanced cancer together with their caregivers. Secondly, the scholars intended to clarify the needs of these patients, and lastly, the level of satisfaction with these services.
Majority of patients and caregivers in this country involved with home based palliative care expressed a preference for palliative day care from a centralized institution. The needs of patients who participated in this study ranged from medical treatment, distraction, information and respite.
This is an article with a wide scope, given that it details the experiences of patients and care givers in Japan. The scope of the article also goes beyond the experiences of patients and care givers in the United Kingdom. It provides an insightful analysis of the case in Japan. However, the article is not conclusive enough. This is understandable given the fact that day hospice care is a relatively new phenomenon in Japan.
Social Objectives in Cancer Care: The Example of Palliative Day Care, Payne M, 2006.
This review article seeks to analyze the social objectives of palliative day care in cancer patients. By analyzing literature, this scholar found that despite the fact that many practitioners realize the need to put into consideration social outcomes of interventions in cancer patients, majority of research in this field leans towards health care outcomes. The scholar identified four social objectives. These include emotional and spiritual well being, conventional social care, social services to family members and care givers and finally, creative arts.
A major strength of this article is that it provides knowledge on a field that is ignored to a larger extent by scholars in the discipline of palliative care. However, one major weakness is that it is a critical literature review in itself. As such, as much as it is providing knowledge on this topic, the knowledge is barely new. It is a reorganization of knowledge already in existence to a larger extent.
The Role of Palliative Day Care in Supporting Patients: A Therapeutic Community Space, Fisher et al, 2008.
This ethnographic study aimed at finding out the experiences of palliative day care patients in Western Australia. These scholars attained this by interviewing eight palliative day care patients. These were two males and six females aged between 44 and 82 years.
The study found that the major concerns for patients receiving palliative day care is being bound physically and socially. They felt limited in their social and physical interaction with the world.
One of the major strength for this article is the fact that the study provides a comprehensive view of experiences of patients within a specific cultural context. As such, the interplay between culture and palliative day care is highlighted. However, the fact that the study made use of a small sample group (8 patients only) puts into question the generalizability of the findings.
Use of a Multi-sensory Environment (Snoezelen) in a Palliative Day Care Setting Resulted in a Small Immediate Reduction in Reported Anxiety, But had no Effect on Quality of Life, Various Authors, 2005.
This article brings together two papers depicting studies carried out by two different sets of scholars aiming to unravel the relationship between Snoezelen and palliative day care. The two papers found that Snoezelen had no effect on quality of life for the patient.
The first paper, A Pilot Study into the use of Multi-Sensory Environment (Snoezelen) Within a Palliative Day Care Setting was written by Schofield and Payne (2005). The second, Doing-being-becoming: Occupational Experiences of Persons with Life Threatening Illnesses, was written by Lyons et al (2002). Both of these papers were based on studies carried out by the authors.
The major strength of this article is the fact that it is a peer reviewed paper. Both papers in this article have been critically appraised, increasing the credibility of the article. However, both of these studies fail to give a deep insight into Snoezelen, assuming that the reader already knows what this is. The researchers immerse themselves into an analysis of Snoezelen within the context of palliative day care without providing a background of this phenomenon. This makes the article a hard to understand literature for individuals who are new to Snoezelen.
This chapter provided a highlight of the critiques done on the articles selected. The articles were original, and they had not been featured in the preliminary literature review in chapter two. A summary of the content of each article was provided, together with the strengths and weaknesses.
The following chapter is analysis of the findings of the study.
In chapter five, the researcher took the reader through a summary of the articles that were identified for this study. All of the ten articles were summarized and their strengths and weaknesses were identified. The researcher also justified the selection of each of these articles for this study. In this section, the reader will be taken through an analysis of the articles summarized in chapter five above. The themes emerging from the articles will be analyzed, whereby major and minor themes will be identified. In short, a thematic analysis will be carried out on these articles.
Themes of the Articles
After critically analyzing all of the ten articles, the researcher identified seven themes. These themes are as listed below:
- Needs of palliative day care patients
- Preferences for palliative day care services
- Palliative day care and social benefits
- Quality of palliative day care services
- The link between palliative day care services and other services
- Palliative day care and quality of life of the patients
- Economics of palliative day care
The above ordering of themes (i-vii) is the same one that will be used in the thematic table that will follow. Several articles shared common themes, while some themes were common to several articles. This will be represented in a theme table below.
The theme table presents the articles against the themes identified:
Table 6.1: Themes and Articles.
|Theme/Article||Theme 1||Theme 2||Theme 3||Theme 4||Theme 5||Theme 6||Theme 7|
|1. Douglas et al (2005), Eliciting patient preferences||X||X|
|2. Low & Wilkinson (2005), Evaluation of Impact||X||X||X|
|3. Douglas et al (2000), Structure of care center||X||X|
|4. Higginson et al (2009), Social Model of Hospice Care||X||X||X||X|
|5. Higginson et al (2003), Effectiveness of palliative Care||X|
|6. Douglas et al (2003), Cost of Palliative Day Care||X||X||X|
|7. Miyashita (2008), Quality of hospice in Japan||X||X||X|
|8. Payne (2006), Social Objectives in Cancer Care||X||X|
|9. Fisher et al (2008), Palliative Day Care and Support||X||X||X|
|10. Various Authors (2005), Snoezelen and Palliative Day Care||X||X|
|Total No. Articles with The Theme||5||5||4||3||3||4||1|
Major and Minor Themes
As the table above depicts, there were major and minor themes in the articles. For the purpose of this study, the researcher considered a theme to be major if it was common in four or more of the ten articles. This means that a minor theme was the one found in three or less of the ten articles.
- Needs of palliative day care patients (Theme 1)
- Preferences for palliative day care services (Theme 2)
- Palliative day care and social benefits (Theme 3)
- Palliative day care and quality of life of the patients (Theme 6)
- Quality of palliative day care services (Theme 4)
- The link between palliative day care services and other services (Theme 5)
- Economics of palliative day care (Theme 7)
Results of Thematic Analysis
As earlier indicated elsewhere in this paper, thematic analysis was used to critically analyze articles for this critical literature review. This means that the themes of the articles identified informed the direction that the critical literature review assumed. As depicted above, seven themes were identified from this analysis. Following is a detailed analysis of these themes:
Theme 1: Needs of Palliative Day Care Patients
This was one of the major themes in this analysis. Five articles had this theme in common.
There are several facets central to this theme. The literature review and thematic analysis of the articles found that there are different needs experienced by palliative day care patients, and this is one of the facets of needs of palliative care patients as a theme (Douglas et al, 2000). These include psychological needs, physical and emotional needs. For example, palliative day care patients need counseling to help them come into term with their illnesses. They also need to be kept informed regarding their health status and what they should expect in the future as their condition advances.
The issue of different needs of palliative day care patients also emerged during the preliminary literature review. This is for example in Douglas et al (2003) where the authors identify psychological needs as some of the various concerns for palliative care providers.
Palliative day care providers strive to identify these needs and address them. This is given the fact that the level of satisfaction as far as these needs are concerned determines the level of satisfaction that patients derive from the services. It is important to note that it is not the patients alone who have needs that should be addressed by palliative day care. Other stakeholders such as family members also have needs, albeit different from those of the patient, which needs to be addressed by palliative day care services. For example, the family members need to be informed on future expectations as far as the health of their patient is concerned (Fisher et al, 2008). However, the patient must be consulted first before information regarding their health is disclosed to any third parties, including their family members (Goodwin et al, 2003).
The other facet of needs of palliative day care patient as identified by thematic analysis is that, the needs vary from one patient to the other and from one time to the other. As Douglas et al (2000) argue in their article analyzed above, needs of palliative day care patients are not a static phenomena; rather, they vary in both space and time. For example, a palliative care patient may be in need of psychological services today, when their physical health is relatively stable (Douglas et al, 2005). However, after admission into an emergency medical facility in the future, their needs may change from psychological to health related, for example alleviation of pain.
There are different patients who are served in a palliative day care facility. These range from those afflicted by cancer to those afflicted by conditions such as HIV/AIDS. Given the different nature of their illnesses, these patients have different needs that should be addressed by palliative day care providers. For example, a HIV/AIDS patient may need psychological counseling while a cancer patient may need pain management services. Two patients may also be suffering from one condition but exhibit different needs. This position in these articles is supported by Payne (2006), who argues that this variation is attributed to the diverse nature of the patients. As such, it is important for the palliative day care providers to treat each case individually and avoid providing services based on the “one size fit all” mantra.
From this thematic analysis, the researcher realized that the extent to which the needs of the patients are met determines the extent to which palliative day care impacts on the quality of life of palliative day care patients. When the needs are met fully, the palliative day care services improve the quality of life of the patients more than when the needs are not met.
Theme 2: Preferences for Palliative Day Care Services
This was also a major theme in the analysis, with five articles addressing it. Thematic analysis of the articles revealed that there are various factors that determine or influence the individual preferences for palliative day care services as far as the patients are concerned.
A case in point is Miyashita et al (2008)’s article analyzed above. According to these scholars, patients in Japan traditionally preferred home based palliative care. This is given that the patients need to be close to their family members especially during the advanced stages of their illnesses. This is an indication that cultural factors are one set of factors that inform preferences for palliative day care services.
Several scholars apart from those whose articles were used for this critical analysis also support this position. For example, according to Kabilan (2003), different individuals express differing preferences for end of life care services such as palliative day care.
Also, analysis of this theme from the articles revealed that different individuals express different preferences as far as palliative day care service is concerned. For example, the aged patients may prefer specialized therapies than the younger patients (Taylor 2009). The differences in preferences are not unlike those in needs for the patients as indicated in theme 1 above. Just like different patients have different needs, so does different patients have different preferences.
Palliative day care service providers should identify the individual preferences for palliative day care services and tailor their services accordingly. They should endeavor to address individual preferences on case to case basis, just like when addressing the different needs of the patients.
It is not every time that a patient access palliative day care services that meets their preferences. This is given the fact that several determinants influence this access. For example, the patient may not access their preferred palliative care due to financial constraints especially in countries where universal health cover is non existent.
Theme 3: Palliative Day Care and Social Benefits
This major theme was common in four articles. The articles revealed that there are several social benefits riding on palliative day care services. For example, patients in a palliative day care centre provide emotional support to one another. The patients also benefit from counseling services provided by professionals in the palliative day care centers (Higginson et al, 2009).
Just like in the case of patients’ needs as far as palliative day care is concerned, thematic analysis of the articles revealed that social benefits go beyond the patients to include their family members. Members of the family also benefit socially when their patients are accessing palliative day care services. For example, the patients become more stable and confident, and as such, they cease to be emotional burdens to their family members (Lovarini & Eva, 2005).
There are several social benefits derived from palliative day care services by both parties (patients and family members). These include emotional support, psychological tranquility among others.
The critical literature review revealed that the ability to deliver social benefits to the patients is one of the major determinants of the extent to which palliative day care improve the quality of life for the patients. If their social needs are met, patients’ lives tend to improve greatly.
Theme 4: Quality of Palliative Day Care Services
This was one of the minor themes addressed by the articles reviewed. Three articles had this theme in common.
There are several determinants of the quality of palliative day care services provided by the various palliative day care centers. This position is the same as that taken by Low, Perry and Wilkinson (2005) when they say that several factors come into play when determining the quality of services provided by end of life care providers.
One factor that determines the quality of palliative day care services is the extent to which the service meets the needs of the patients and in extension, those of the family members. For example, a palliative day care institution will be considered to provide quality services to the patients when the services address the social, health and other needs of the patients. The quality of the services is also determined to some extent by the degree to which the services provided are aligned with the individual preferences of the patients. For example, if the services are tailored to address the individual needs and preferences of the patients, then they can be taken to be of high quality (Miyashita et al, 2008).
It is important for the palliative care providers to be informed on ways to improve the quality of their services. This is given the fact that there is a positive relationship between the quality of the services provided and the extent to which palliative day care improves the quality of life for the patients. Quality service is one of the factors leading to improved quality of life for the patients.
Theme 5: The Link between Palliative Day Care Services and other Services
This was also a minor theme, whereby only three articles out of the total ten addressed it.
Payne (2006, p.440) notes that any service provided for end of life patients can not be analyzed as a stand alone phenomenon. This is given the fact that there are other services out there that either complement or hinder the delivery or utilization of these services. This position supports the argument made by authors of the various articles analyzed; there is a link or interplay between palliative day care and other services availed to end of life patients in the community.
There are different services that are utilized by end of life patients in the contemporary society. These include hospice care for cancer patients among others. Palliative day care is such one service made available to these patients.
Thematic analysis revealed that patients accessing palliative day care services are likely to benefit from other services that are offered in conjunction with them at the palliative day care centers. This is as opposed to those patients who do not access palliative day services. For example, apart from receiving medical based and other specialized therapies, the patients can access other services such as counseling.
Consumption of palliative day care services does not impact negatively on demand for other services that are not provided by palliative day care centers (Ringdal et al 2004). For example, the fact that patients attend day care centers does not mean that they will support consuming other services such as the spiritual guidance and support provided by religious organization for end of life patients.
Thematic analysis also revealed that complementing palliative day care services with other services provided by the community improves the extent to which palliative day care services improves the life of the patients. For example, the life of the patient will be greatly improved if they can access both medical and social support from the community.
Theme 6: Palliative Day Care and Quality of Life of Patients
This was another major theme in the analysis. Four articles had this theme in common.
Palliative day care is connected to some extent with the quality of life for the patients. When the services provided by palliative day care centers meet the needs of the patients as well as their preferences, then the quality of life for the patients tend to improve.
However, it is important to note that palliative day care services alone can not improve the quality of life for the patients. There is need to complement this care with other services provided by the community to ensure that all facets of the patient’s life are addressed. For example, health care from the palliative day care centers should be complemented by social support from family members and other members of the society.
Theme 7: Economics of Palliative Day Care
This was one of the minor themes that were addressed by the least number of articles. To be precise, only one article had the theme of economics and palliative day care running through it.
Thematic analysis revealed that the quality of palliative services provided by palliative day care centers is greatly dependent on the amount of resources at the disposal of the institution. A well funded institution is able to hire professional care givers and hence able to improve the quality of services provided.
It is important for the palliative day care managers to be able to compute the cost of providing care for one patient in a day. This way, they will be able to determine the number of patients that can be comfortably handled by the centre. They can also be able to identify resource limitations and address them early before they impact on the quality of services provided.
From thematic analysis provided above, it can be noted that the themes identified are interlinked. This is to mean that one theme may have other sub-themes within it. As such, the thematic analysis can not be conceptualized in isolation.
Type of Thematic Analysis used
There are different thematic analysis methods that can be used in a critical literature review. An analyst can use mind diagrams, fish bone diagrams among a myriad of other techniques to map themes in articles.
For the purpose of this study, the researcher used a spider diagram to map the themes of the articles. This was selected given the fact that the researcher found it possible to map the themes clearly with the diagram. This is as indicated below:
In this chapter, the researcher took the reader through the thematic analysis for this study. The themes emerging from critical appraisal of the ten articles identified were presented. Seven themes in total were identified. These included four major themes and three minor themes.
The number of themes and then number of articles that addressed them was presented in a thematic table. An insightful analysis of these themes was then given. The relationship or link between each of the themes and knowledge in other articles in the field was presented where necessary. The researcher closed this chapter by a presentation of the spider diagram that was used to map the themes in the articles.
The following chapter is going to include the discussion on the findings of this analysis. The implications of the findings to research questions identified at the start of this paper will be addressed in this chapter.
The study identified 10-15 articles of primary research with a view to aiding the research in answering the research questions of the study. The relevance of the articles was based on the way they proposed management of pain, depression or anxiety and dyspnoea (Higginson et al 2003). Besides the literature on diseases like cancers, most part of the research concentrated on patients with advanced sickness and not entirely the terminal illness (Fisher et al 2008). This is because the intention of the study was to investigate services of palliative day care centre rather than the end-of-life process. The evidence obtained for improving care; dyspnoea and care continuity depend on this indirect facts. Most of the proof came from one setting and a number of intervention reports that address nursing at palliative units (Brumley, Enguidanos, Cherin 2003).
Better means of improving care when managing pain included the use of pharmacological agents. The beta agonists and morphine were the drugs of choice. However, another means of management was carrying out the pulmonary rehabilitation and supplying oxygen to manage symptomatic care in COPD. Other opioid analgesics were weakly supported for use in cancer patients. Several disciplines came in to reduce wrong use. Antidepressants were use to reduce major melancholy. No specific palliative care service was found to be the most effective and none was also found to improve depression more (Payne 2006).
Evidence for Better Service
Recent studies showed that management of the symptoms was the major function of palliative care at day care units. Since this study indicated that treatment was effective, evaluation and follow up of the symptoms – pain, depression and dyspnoea are the priority. Palliative care experts could have been very effective due to their way of operating (Langley-Evans 1997). They ensured screening of the signs, better and multifaceted treatment and also carried out follow ups. The priorities were set as assessment and management of non-cancer pain, management of dyspnoea among cancer patients and management of depression in the terminal life cases.
The former study emphasized on administrative and use outcomes of further care. This is because there missed patient oriented and non- family focused research.
Nonetheless, the recent investigation focused more on wider interventions that included training the facilitators and use of experts in important decision making activities across the day care setting (Langley-Evans 1997).
Palliative care trails continue to improve in recent studies and translate to better continuity though this has not compared different approaches. The studies on heart failure have shown that effectiveness of a wide-ranging plan of intervention ensures full support across time and background (Hearn & Myers 2001). At the end of life as the patient goes through complex transitions of the disease, care coordination usually becomes very hard. The studies on care giving were mainly addressing dementia, whereby individual intervention was successful in attaining the required treatment results (Langley-Evans 1997). Group intervention on the other hand dominated in literature. Although several measures were consistently applied, the outcome were relatively minimal, the future results would be beneficial if it would be set to make comparisons of the alternatives mean and include other regular patient conditions.
This review has been observed to have limitations in that most of appropriate literature to these domains and the advanced care for the patients do not have a common identification term or key search word used for indexing (Gitlin et al 2003). To deal with this challenge, the researchers conducted disease specific extra search. This could have on there other hand lost some vital information for citation. The research missed to address other debatable matters like religious concerns and technical response about the matter. Therefore future reviews will have to address these subjects to more details (Hearn & Myers 2001).
This systematic review was able to identify interventions that could produce substantial improvements in the progressive illness experience. For instance, evidence that improvement of cancer pain and the total alleviation of adverse symptoms obviously unjustifiable (Gitlin et al 2003). The fast enactment of modern knowledge ensures that patients receive optimum care throughout the illness period (Low et al 2005). The search for the study was not comprehensive because of the limited literature index about critical diseases and illness. Heterogeneity was also over extensive meta-analysis. More research need to be done in order to measure the resultant effects and also combine the results through the lifespan of the disease on a patient (Jordhøy et al 2001). There are many critical issues that are not supported by high-quality evidence.
Making major progress at the stage of persistence diseases and infirmity is critically important. Most patients worldwide who fight the disease signs and infirmities die at this stage.
It is estimated that about 30 percent of the expenses that Medicare has made are usually because of the patient’s progressive illness and particularly the last days of life. And the outlays increase as the population continues to age (Low et al 2005). Over 25 percent of the hospitals in America operate palliative care services and currently, there has been increased specialization of this type of care so as to ensure that most services are provided to meet the diverse needs of the patients. Many patients often tend to go though characteristic clinical symptoms or function loss as the disease progresses to the terminal stages (Jordhøy et al 2001).
Cancer has exemplified this clinical course and the last days are characterized by complete loss of activity. Contrary to this is the organ system failure which on the other hand tends to cause problems that are long term and also presents intermittently with periods of wellness and exacerbation and this has made timing of the last days almost unpredictable. Dementia patients loss functionality slowly and this conditions described by frailty (Low et al 2005).
Regardless of the progress that has been made in improving palliative care, there is evidence that some vulnerable population around the world still have unmet need (Acton & Kang 2001). They have been excluded from these advances and cannot access the best service. They include the less affluent families, populations of the minority ethnic group and children and the seniors. The underlying reasons for these variations are not very clear (Jordhøy et al 2001). They could indicate the untested assumption concerning the capacity and desire of various groups in coping without special type of assistance available, lack of the ability to detect concerns, discrimination or other general problems about the structure of the healthcare system.
Populations that live in poverty have been found to report the highest number of deaths from chronic diseases like cancer. These people are more likely to die in hospitals than at home. The reason is that they cannot afford palliative care before the symptoms get serious but rush for emergence care when the life of the patients is totally threatened (Jordhøy et al 2001). Such results have been indicated in the United Kingdom and also in Italy. This means that home care has not been effective. However with day care services at reachable range close to the residents, palliative care can be effective.
Groups like the homeless, those with learning difficulty, patients undergoing long-tern psychiatric therapy and prisoners can be a problem when it comes to offering palliative care a day care centre (Langley-Evans 1997).
People from various backgrounds usually experience psychological problems when diagnosed with progressive illness. They suffer spiritually and the existence crisis develops. These crises are very critical and care givers need to know when to seek for assistance from various experts of faiths and social beliefs (McDonald et al 2005). Cultural diversity can therefore restrict people from attending day care services because they feel that their faiths are not well recognised and appreciated. The patient autonomy is at stake since getting to understand the patients and helping them accept their condition could be a very difficult job (Jennings et al 2002).
Though much knowledge has been developed to address palliative care best service, the impact cannot be felt if it’s not put to work by the experts in the correct setting. Day cares present the opportunity to do this. It’s quite obvious now that having the knowledge of palliative care is not a guarantee that there will be improvement of service delivery without the proper effort being done to change the setting of the practise (Jennings et al 2002). Many of the setting hence attempt to develop more systematic means of making use of the available knowledge to enhance care (Salisbury et al 1999). The effort that have been done include changing the setting, structure of the health facilities, processes and behaviour but this is not simple or easy (Low et al 2005). The reviews have shown that the initiatives have to be locally developed and they need to be evidence based as much as possible. Evidence has to be from education, multi-professional collaboration, patient feed back and effective management. For this reason, there are audit tools that have been developed for measurement in palliative day care to assess the required outcomes (Acton & Kang 2001).
There is some improvement in the delivery of service in palliative care. This change has been observed in the recent past though traditionally, this sector has been of lesser profile in terms of education and professionals. Many of the past research papers have not information about palliative care except few that highlight prognosis of chronic illnesses (Grande et al 1997). This could be the explanation why practitioners in most cases report they did not feel adequately trained to break the bad news to the patient, his/her family, assess progress, manage the severe symptoms and assist patient in making difficult decisions. This could also be the explanation as to why there is always late referral of patients to palliative care or some mist it altogether. Nonetheless, some encouraging evidence shows that there are improved skills or care obtained from extra training (Acton & Kang 2001, p. 349).
Patient Needs Addressed
The results of this study depicted three themes. First was that there are some need of patients who make use of the day care palliative service that have not been addressed. These needs are also variable depending on personal characteristics of the patients. In order for the patient to benefit, there needs to be assessment of the patient needs and the capacity to benefit. Still, the ability to benefit form the service varies on a daily basis (Jennings et al 2002). However, assessments of the centers have shown that these day care centers have become successful in meeting their objectives. Its very had on the other hand to assess the number of patient tat can be supported by the organization despite the ability of these centers in creating quite environment that is responsive and supportive to the variety and the ever-changing needs of the patients (Jennings et al 2002).
Second, there is flexibility of service though the utilization of the resources used depends on several factors that cannot be easily regulated by mangers. Palliative day care benefit from donated resources and volunteer staff, Sometimes this means that the services available will be dependent on the willingness of the volunteers to avail themselves (Grande et al 1997).
Third, the review reveals that regardless if the various origins, developing palliative day care had some similarities across the profile. Most of them combined social support and therapeutic intervention and the intention was to ensure assessment and therapy. Most day care centers offered service as a package of complimentary therapies (Gitlin et al 2003).
Regardless if the similarities that the day care centers show differences in the physical setting and philosophy of care are a great challenge when making assessment of the costs and the benefits of general services (Singer, Martin & Kelner 1999). Additionally, holistic approach of offering care in such centers makes the process even more complex for comparisons of palliative care with other medical and social services (Grande et al 1997).
Readers should not assume that since systematic literature review method does not use of primary data collection techniques or face the challenges in the field and that there are no participants it would not face ethical challenges (Slater & Freeman 2004). This is far from reality. There are even more ethical issues that are involved around affecting the research findings of the reviewed articles (Schofield 2003; Pan et al 2001).
The researcher will uphold the requirement of maintaining fairness and honesty when presenting research data, For instance, the interpreting the data in a malicious way and bringing out the meaning that was not intended by the investigator. This study being a systematic literature review, the researcher may be tempted to skew the findings to fit their personal goals. Most importantly, the intention of the researcher was to make sure the information from other writers is acknowledged, to avoid presenting other people’s information as their original findings (Schofield 2003). Using people’s works without referencing them would result into the crime of plagiarism. This is a very bad academic crime that any scholar can commit in research especially since the method of study is literature review of previous already researched information.
This information has to be used cautiously with caveat that it could be very difficult to transfer the outcomes to another setting based on the general population to the ailing one or the more vulnerable group like elderly. Specific statistics for different types of patients will definitely be of critical importance to the service providers working with patients with progressive condition.
Recommendations and Conclusions
Palliative care objectives are to take care of the physical, emotional and social wellness of patients and their care providers. The care is given to individuals who are struggling with illnesses that could lead to death after worsening (Song 2005). The care should not be restricted to the end life when the patient becomes moribund. Good palliative care can assist in alleviating the painful suffering that is characteristics of this period. First, the process of intervention begins by assessing the needs of the patients from the symptoms presented, and then the caregivers can offer psychological and social assistance to these patients accordingly (Acton & Kang 2001).
With regard to patient population, generally, everybody that has suffered serious illness that could probably lead to disabling of the patients. The condition could also be symptomatic chronic illness. The study has offered some of the basic aspects of palliative day care which require consideration when creating a research to assess the service delivery from a day care. It does not exactly provide instinct solutions for developing adequate measurement tool, but it offers insights into dimensions that can be considered critical in a bigger assessment research. It could also offer insights which are beneficial for other research into complex intervention that go beyond the social and medical divide. The major points are indicated as;
First, the measurement of the advantages of the services is complicated since patients have critical but varied needs and other actors like care givers and family members all have to benefit from that service that can balance and affect each other in a delicate manner (Higginson 2003). Palliative care could also substitute other care that could be even more costly and such benefits also need evaluation. The advantages of this to the patients suffering from progressive illness are necessarily measured in terms of duration in most cases. Conventional measures of the benefit like improvement in the quality of life are restricted to the quality in assessment of this type (Cook, Finlay, Edwards, Hood, Higginson & Goodwin 2001). Determination of the economic benefit to the patients and the practitioners will require more clever study tools, possibly of expressive nature at this point. Means of measuring the economic benefits of intervention whereby results will require further development in this field (Mitchell 2008).
The issue of palliative care costing also faces serious obstacles (Solano, Gomes & Higginson 2006). The alleged under-utilization of the centers which could as well be necessary considering that the nature and quick change of the illness of the patient is incoherent. This therefore means that there is a problem with the ratio of cost per patient (Currow, Abernethy & Fazekas 2004). The value could be overestimated when considering care for individual patient. It would as well fail to cover for the cost of taking care of the patient’s family and care givers. Care has to be interpreted in terms of the economic benefit particularly in the areas that are of importance to the volunteers (Mitchell 2008). Whereas the conventional economist reaction is to quantify unpaid effort at the next best alternative, it is very hard to evaluate what this could be (Cynthia & Malcom 2005). For instance, the volunteers could get employed by other means then the cost of their labor in terms of the salary forfeited by volunteering should be calculated. Nonetheless, if this happens to be the single may of employing their time at palliative care, then theory-wise, the economic value of their labor is nil (Higginson 2003).
The study did not consider observational study by rating the change and expansion of the care service with time/ there are several centers that have increased in scope and they can handle variety of conditions. Such bigger capacity is important as needs keep on evolving with time and there need to be an expansion policy in place.
Finally, addressing the specific needs of patients is a major concern. Many people ask whether cancer patient had specific needs that were not present among other patients of progressive and chronic illness (Dangel 2002). The basis of this concern is that there are many studies that have developed based on cancer than any other disease. There is very little evidence to indicate the reason behind this trend (Mitchell 2008). This clearly shows that there is no high quality evidence currently to show that cancer has special needs. The paper does not address many aspects of palliative care. The review missed to include spiritual therapy, support for nutrition and also other substitute therapy (Davies & Higginson 2005). If certain interventions are not assessed, it does not mean that they do not have any impact on the outcomes, but shows that the intervention was not sufficiently investigated to express it efficacy.
Management of symptoms, continuity of care and reduction of the burden to the care givers are the major aspects of service to the progressive care patients. Additionally, proper treatment means to handle pain, depression and dyspnoea are critical and greatly affect the wellbeing patients in this situation. Trained facilitators and providers are very critical and necessary (Sörensen et al 2002). The services should also involve major decision makers and address care for patients and also take care of other relevant resources and people who work towards improving care. Still, there needs to be further research that would investigate more information on the possible benefits of palliative day care. This should come up strongly to investigate other chronic health conditions beside cancer, as many researches have already addressed cancer (Sörensen et al 2002).
The first recommendation is that care givers and practitioners should constantly assess their patients for depression, pain and feeling of breathlessness. It is common to find patients who need palliative care presenting serious signs of pain (Bennett et al 2000). There is also discontinuity of care and the care giver experiences substantial burden due to the needs of the patients. The patients are very dependent as their daily function is affected by the disease. These concerns are critical important to the patient and the family. Even though each patient needs individualized evaluation and care, the evidence indicates that a set of general concerns are common among many patient that need palliative care (Bennett et al 2000). These concerns include management of pain among other signs of progressive illness. They also need care coordination, psychological guiding and counseling and advance care plan. The evidence is moderate as it was derived from studies of cancer patients and was particularly heterogeneous (McLaren et al 1999). This calls for the second recommendation which is training of the palliative care practitioners.
Service delivery at a palliative day care centre is just part of the greater medical fields with diverse health needs. The larger field interrelates with other specialties in a unique manner. Palliative care being relatively novel, specialist training is very important (Windham et al 2003). The rationale behind the new advance is that, there needs to be knowledge available to all practitioners of various specialties so as to guarantee quality in service delivery. This will also establish the minimal qualifications that practitioners will have to be competent in order to be allowed to practice in this field. This is of great importance considering that very patient has a right to care. However patients attending this type of care are experiencing symptoms of chronic illness but has limited prognosis. The focus of the care is to relieve the symptoms or the suffering brought about by tease symptoms (Windham et al 2003). The wellbeing of the patients is important and ultimately, the quality of life has to be improved.
The development of palliative knowledge as ever before, focuses on management of pain and other making life comfortable (Higginson et al 2010). Holistic approach targets management of emotions, spiritual needs and family needs. Palliative care usually begins long before terminal phase comes to play. This is the point at which specialized palliative care will be greatly needed. Indeed, a very low number of patients in the day care would need specialized treatment as many tend to be accompanied by family doctor (Bennett et al 2000). Right from the diagnosis phase, the doctor begins offering service to manage the symptoms. So as to offer highly specialized care for the patients who attend day care services, and in order to avoid problems of dealing with complications and prejudice, the palliative care practitioners need extensive understanding of this type of care (Higginson et al 2010). A cautiously and adequately trained team can offer professional service to meet the needs of the family and patient without limited professionalism and experiencing a burnout. Nurses, doctors and social workers need thorough training as indicated that this is relatively new practice. Dealing with issues of illness, caretaking, anxiety, disagreement on best care, financial constraints and organization problems is not very easy. For social workers to help patients and families manage this, they require more knowledge and skills for doing this job (Windham et al 2003).
Third recommendation is that care givers and practitioners should use the therapies that have been certified and proven effective in managing symptoms of chronic illnesses. This is in the spirit of adhering to the philosophy of evidence-based practice (Higginson et al 2010). From the literature review, there was evidence that some therapies or interventions worked best in certain conditions. Non-steroidal analgesics and opioid analgesics were strongly supported for managing acute and chronic pain. There was strong evidence to support the use of opioids in management of breathlessness in dyspnoea in cancer patients (Jack just double check that this is not his first name instead of his surname et al 2003). Hypoxemia can be managed efficiently by providing oxygen supply in advanced chronic obstruction of the pulmonary. Beta agonist are also supported in manage of dyspnoea in COPD.
Palliative day care offer better services that any other setting, better that home care. It combines different approaches to improve the health of individuals afflicted by progressive illnesses and conditions. The effectiveness of palliative care arises from the fact that the setting is designed to cater for all the aspect of health that patients need to benefit from when attending the day care centre. These aspects include social support, professional or expert service, spiritual support and psychological guidance. This means that the patient will be relief of the physical suffering after undergoing the therapy, and will also handle other distressing symptoms by assessing profession services from experts in the field. Their emotional and social wellbeing will be relived by social workers and interaction with other patients. Of particular importance to this care is the team work.
Day care services are provided by a team, this way, patient’s needs are addressed together withy those of their families. The service extends to even bereavement and provides counseling to grieving family members and instils hope and understanding in the ailing patients. This care enhances the quality of living with the condition and positively influences the direction of the illness. The services can be applicable nearly stages of the illness alongside their therapies to prolong life. Patients can visit the day care 3-5 times a week and the services are provided based on the developing needs. Though not an integral part of health care, palliative day care services have shown that they are effective since patients who attend these centers have prolonged and better quality life despite their health condition. Through palliative care, individuals are relieved from severe pain and the effects of distressing symptoms.
Palliative care has been identified as an important consideration in caring for individuals with chronic diseases when they are approaching the end of their life. Through the care, end of an individual’s life is considered to be a normal process. Palliative care does not only help individuals suffering from chronic diseases to lead a normal and active life but also helps the family members and friends to cope with the situation. Members of the family also benefit socially when their patients are accessing palliative day care services. For example, the patients become more stable and confident, and as such, they cease to be emotional burdens to their family members.
From the study, it is evident that the effectiveness of palliative care can be attained through incorporation of a team approach. Apart from health care offered through palliative day care, the service also enables the patients to access other therapies. Thematic analysis revealed that patients accessing palliative day care services are likely to benefit from other services that are offered in conjunction with them at the palliative day care centers. This is as opposed to those patients who do not access palliative day services. Some of these services relate to radiation and chemotherapies. The core objective of these therapies is to prolong life. Complementing palliative day care services with other services provided by the community improves the extent to which palliative day care services improves the life of the patients.
Acton, G.J., & Kang, J. 2001. Interventions to reduce the burden of care giving for an adult with dementia: a meta-analysis. Res Nurs Health. Vol. 24, pp: 349-60.
Anson, CM and Schwegler, RA.2000. The Longman Handbook for Writers and Readers, Second edition. New York: Longman.
Au D. H., Udris E. M., Fihn S. D., McDonnell M. B. & Curtis J. R.,2006. Difference in health care utilization at the end-of-life among patients with chronic
obstructive pulmonary disease and patients with lung cancer. Arch Intern Med, 166:326-331.
Baker, R., 2000. Family satisfaction with end-of-life care in seriously ill hospitalized adults. J Am Geriatr Soc.48:S61-9.
Benini F, Spizzichino M & Trapanotto, M., 2008. Childhood Deaths Caused By Life-Limiting and Life-Threatening Disease in Italy. European Journal of Palliative Care. Vol. 15, pp. 77-81.
Bennett, M., Ahmedzai, S. H., 2000. Evidence-Based Clinical Guidelines for Palliative Care: The Work of the APM Science Committee. Palliat Med. Vol. 14, pp: 453-45.
Brazil K., Bedard M., Kruger P., Taniguchi A., Kelly M.L., McAiney C & Justice, C., 2006. Barriers to providing palliative care in long-term care facilities. Can Fam Physician.Vol. 52, pp. 473-478.
Burns R., Nichols L.O., Martindale-Adams J., Graney M.J & Lummus,A.2003. primary care interventions for dementia caregivers: 2-year outcomes from the reach study. Gerontologist. 43:547-55.
Brumley, R.D., Enguidanos, S., Cherin, D.A., 2003. Effectiveness of a home-based palliative care program for end-of-life. Journal of Palliative Medicine Vol. 6, issue 5, pp:715-724.
Cook, A.M., Finlay, I.G., Edwards, A.G., Hood, K., Higginson, I.J., & Goodwin, D.M., 2001. Efficiency of searching the grey literature in palliative care. J Pain Symptom Manage; Vol.22, pp: 797-801.
Currow, D.C., Abernethy, A.P., & Fazekas, B.S., 2004. Specialist palliative care needs of whole populations: a feasibility study using a novel approach. Palliative Medicine; 18 (3): 239-247.
Collins J.J., Byrnes M.E., Dunkel I.J., Lapin J., Nadel T., & Thaler H.T., 2000. The Measurement Of Symptoms In Children With Cancer. Journal Of Pain And Symptom Management, 19:363-377.
Cooper, H.M., 1988. The structure of knowledge synthesis”, Knowledge in Society, vol. 1, 104-126.
Cynthia, K., & Malcom, P., 2005. Understanding why palliative care patients ‘like day care’ and ‘getting out’, Journal of Palliative Care, vol. 21, no. 4, pp. 292-298.
Dangel, T. 2002. The Status of Paediatric Palliative Care In Europe. Journal of Pain and Symptom Management. Vol. 24, pp:160-165.
Davies, E., & Higginson, I.J. 2005. Systematic review of specialist palliative day-care for adults with cancer, Support Care Cancer Aug; Vol. 13, issue 8, pp 607-627.
Dangel, T.,2002. The Status of Paediatric Palliative Care In Europe. Journal of Pain and Symptom Management, 24:160-165.
Danson, B., 2007, Seven steps to systematic literature reviews, retrieved from ; 2010.
Dellinger, V. 2005.Critical literature review as a research methodology.Knowledge in Society, vol 2, 30-38.
Douglas, H.R., Higginson, I.J., Myers, K. & Normand, C.2000. Assessing structure, process and outcome in palliative day care: a pilot study for a multi-centre trial. Journal of Health and Social CARE Community. 8(5): 336-344.
Douglas, H.R, Normand, C. E, Higginson, I.J & Goodwin, D. M. 2003.Palliative day care: what does it cost to run a centre and does attendance affect use of other services? Keppel Street, London: London School of Hygiene and Tropical Medicine.
Edmonds, P., Karlsen, S., Khan, S., & Addington-Hall, J. A. 2001. A Comparison Of The Palliative Care Needs Of Patients Dying Chronic Respiratory Diseases And Lung Cancer. Palliat Medl Vol. 15, pp: 287-295.
Feudtner C., Santucci G., Feinstein J.A., Snyder C.R., Rourke M.T., & Kang T.I,2007.
Hopeful Thinking And Level Of Comfort Regarding Providing Paediatric Palliative Care: A Survey Of Hospital Nurses. Paediatrics, 119:186-192
Field, M.J., & Cassel, C.K., 1997. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academies Press.
Finlay, I., Higginson, I.J., Goodwin, D., Cook, A., Edwards, A., Hood, K., 2002. Palliative care in hospital, hospice, at home: results from a systematic review. Annals of Oncology; 13(Supplement 4):257-264.
Fisher, C., O’Connor, M. & Abel, K., 2008. The role of palliative day care in supporting patients: a therapeutic community space. International Journal of Palliative Care. Vol. 14, issue 3, pp: 117-125.
Freeman, D., & Price, D. 2001. Primary care and palliative care. BMJ. Vol. 333, pp:188-190.
Gitlin, L.N., Belle, S.H., Burgio, L.D., Czaja, S.J., Mahoney, D., Gallagher-Thompson, D. (2003). Effect Of Multi-Component Interventions On Caregiver
Burden And Depression: The REACH Multisite Initiative At 6-Month Follow-p. Psychol Aging. Vol.18, pp: 361-74.
Goodwin, D.M, Higginson, I.J., Myers, K., Douglas, H.R & Normand, C.E. 2003.
Effectiveness of palliative day care in improving pain, symptom control and quality of life. Journal of Pain and Symptom Management. Vol. 25, issue 3, pp: 202-212.
Gomm, S., Hobson, K., Murtagh F, & Caress A.L., 2010. A National Survey of Specialist Palliative Care Services For Patients With End Stage Renal Disease. Palliative Medicine, Vol. 24 Issue 2, pp: 202.
Gore, J.M, Brophy C.J, & Greenstone, M.A., 2000. How well do we care for patients end stage chronic obstructive pulmonary disease (copd)? A comparison of palliative care In Copd And Lung Cancer. Thorax. Issue 55, pp:1000-1006.
Grande, G.E., Todd, C.J., & Barclay, S.I.,1997. Support Needs In The Last Year Of Life: Patient And Carer Dilemmas. Palliat Med; Vol.11, pp: 202-8.
Green, BN Johnson, C.D & Adams, A., 2006. “Writing Narrative Literature Reviews for Peer-Reviewed Journals: Secrets of the Trade”, Journal of Chiropractic Medicine, 5(6), 110-115.
Groot, M.M., Vernooij-Dassen M.J., Crul B.J. & Grol, R.P., 2005. General practitioners (gps) and palliative care: perceived tasks and barriers in daily practice. Palliative Medicine ,19:111-118.
Hannan ,J., & Gibson, F.2005. Advanced cancer in children: how parents decide on final place of care for their dying child. Health And Social Care In The Community, 13:441-450.
Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfield, B.H., Adair, C.E., Mckendry, R. 2003. Continuity of care: a multidisciplinary Review. BMJ. 327:1219-21.
Hannan, J., & Gibson, F., 2005. Advanced cancer in children: how parents decide on final place of care for their dying child. Health And Social Care In The Community, 13:441-450.
Hanson, L.C, Tulsky, J.A., Danis, M. 1997. Can clinical interventions change care at the end- of- life? Ann Intern Med; 126: 381-8.
Hanson, L.C., Danis, M., Garrett, J. 1997. What is wrong with end-of-life care? opinions of bereaved family members. J Am Geriatr Soc; 45:1339-74.
Hearn, J. & Myers, K. 2001. Palliative Day Care in Practice, Oxford: Oxford University Press.
Hannah-Rose, D., Normand, C., Higginson I. J & Goodwin, D.M.,2005. A new approachto eliciting patients’ preferences for palliative day care: The choice experiment method. Journal of Pain And Symptom Management. Vol. 29, issue 5, pp: 434-445.
Hart, C., 2004, Doing your master’s thesis, London: Sage.
Hearn, J. & Myers, K.,2001. Palliative Day Care in Practice, Oxford: Oxford University Press.
Higginson, I.J., Gao, W & Amesbury, B. 2010. Does A Social Model Of Hospice Day Care Affect Advanced Cancer Patients’ Use Of Other Health And Social Services? A Prospective Quasi-Experimental Trial Support Care Cancer. Vol.18, pp: 627–637.
Higginson, I., 2003. Palliative care: a review of past changes and future trends. Journal of Public Health, Vol. 15, No. 1, pp. 3-9.
Higginson, I., Finlay, I., Goodwin, D., Hood, K., Edwards, A., & Cook, A., 2003. Is There Evidence those Palliative Care Teams Alter End-Of-Life Experiences Of Patients And Their Caregivers? Journal Of Pain And Symptom Management; 2 Vol. 5, issue 2, pp:150-68.
Himelstein, B.P., Hilden J.M., Boldt, A.M. & Weissman, D.2004. Paediatric Palliative Care. New England Journal Of Medicine, 350:1752-1762.
Hopkinson. J.B & Hallett, C.E., 1999. Patients’ perceptions of hospice day care: a phenomenological study, International Journal Of Nursing Studies, Vol. 38, Issue 1, pp: 117-125.
Jack, B., Hillier, V., Williams, A., & Oldham, J. 2003. Hospital Based Palliative Care Teams Improve The Symptoms Of Cancer Patients. Palliat Med. Vol. 17, pp: 498-502.
Jemal, A., Ward E., Hao Y., & Thun M., 2002. Trends In The Leading Causes Of Death In The United States, 1970–2002. JAMA 2005, 294:12
Jennings, A.L., Davies, A.N., Higgins, J.P., Gibbs, J.S., & Broadley, K.E.,2002. A Systematic Review Of The Use Of Opioids In The Management Of Dyspnoea Thorax. Vol. 5, pp: 939-44.
Jordhoy, M.S., Fayers, P., Loge, J.H., Ahlner-Elmqvist, M., & Kaasa, S.,2001.
Quality Of Life In Palliative Cancer Care: Results From A Cluster Randomized Trial. J Clin Oncol. Vol. 19. Pp: 3884-94
Kabilan, M.K., 2003. Writing critical literature review, School of Educational Studies, University Sains Malaysia. 37-48.
Keeley, P.W. 2008. Improving the evidence base in palliative medicine: a moral imperative. J. Med. Ethics 34: 757-760
Kernohan, W.G., Hasson, F., Hutchinson, P., & Cochrane, B. 2006. Patient Satisfaction With Hospice Day Care, Support Care Cancer, 14: 462–468
Kernohan, W.G., Hasson, F., Hutchinson, P., & Cochrane. 2003. Patient satisfaction with hospice day care, Supportive Care in Cancer, Vol. 4, Issue 5, pp 462-468.
Langley-Evans, A. 1997. light-hearted death talk in a palliative day care context. Journal Of Advanced Nursing, 26, 1091-1097.
Latimer, E.J., Crabb, M.R., Roberts, J.G., Ewen, M., & Roberts, J. 1998. The Patient Care Travelling Record In Palliative Care: Effectiveness And Efficiency. J Pain Symptom Manage; 16: 41-51.
Lorenz, K., Lynn, J., Morton, S.C., Dy, S., Mularski, R., Shugarman, L., Sun, V., Wilkinson, A., Maglione, M., Shekelle, P.G. 2004. End-of-Life Care and Outcomes. Evidence Report/Technology Assessment No. 110. AHRQ Publication No. 05-E004-2. Rockville, MD: Agency For Healthcare Research And Quality.
Lorenz, K.A., Lynn, J., Morton, S.C., Dy, S.M., Shugarman, L.M., Wilkinson, A. 2005. Methodological Approaches For A Systematic Review Of End-Of-Life Care. J Palliat Med. 8 Suppl 1:S4-11.
Low, J., Perry, R., & Wilkinson, S. 2005. A qualitative evaluation of the impact of palliative care day services: the experiences of patients, informal carers, day unit managers and volunteer staff, Palliat Med 2005; 19; 65-70
Lunney, J.R, Lynn, J., Foley, D.J., Lipson, S., Guralnik, J.M. 2003. Patterns of functional decline at the end of life. JAMA; 289: 2387-92.
Lovarini, M. & Eva, G., 2005. Use of a multi-sensory environment (Snoezelen) in a palliative day care setting resulted in a small immediate reduction in reported anxiety, but had no effect on quality of life. Australian Occupational Therapy Journal. Vol. 52, issue 2, pp: 171-172.
Low, J. Perry, R. & Wilkinson, S., 2005. A Qualitative evaluation of the impact of palliative day care services: the experiences of patients, informal careers, day unit managers and volunteer staff. Palliat. Med. Vol. 19, issue 1, pp: 65-70.
Low, J., Perry, R., & Wilkinson, S., 2005. A Qualitative Evaluation Of The Impact Of Palliative Care Day Services: The Experiences Of Patients, Informal Carers, Day Unit Managers And Volunteer Staff, Palliat Med. Vol.19, pp: 65-70.
McLaren, G., Preston, C., Grant, B., Lovel, T. 1999. Evidence based palliative care. BMJ 319: 1573.
McCormack, P., 2010. Improving Palliative Care Standards Through Partnerships, Palliative Medicine. Vol. 24, Issue 2 Pp. 207
McDonald M.V., Pezzin, L.E., Feldman, P.H., Murtaugh, C.M., & Peng, T.R., 2005.
Can Just-In-Time, Evidence-Based “Reminders” Improve Pain Management among Home Health Care Nurses and Their Patients? J Pain Symptom Manage; Vol. 29, pp: 474 – 88.
Mitchell, G. 2008. Palliative Care: A Patient–Cantered Approach. Oxford, UK, Radcliffe Publishing.
Miyashita, M., Misawa, T., Abe, M., Nakayama, Y., Abe, K. & Kawa, M., 2008. Quality of life, day care hospice needs and satisfaction of community-dwelling patients with advanced cancer and their care givers in Japan. Journal of Palliative Medicine. Vol. 11, issue 9, pp: 203-207.
Morrison, L.J & Morrison, R.S.,2006. Palliative Care and Pain Management. Med Clin North Am. Vol. 90 pp. 83-1004.
Morrison, R.S. & Meier D.E., 2004. Palliative Care. N Engl J Med, 350:2582-2590.
Morrison ,R.S., Maroney-Galin C., Kralovec P.D., & Meier D.E.,2005. The Growth Of Palliative Care Programs In United States Hospitals. J Palliat Med, 8:1127-1134.
Mularski, R.A., Dy, S.M., Shugarmanm L.R., Wilkinson, A, M., Lynn, J., & Shekelle, P.G., 2007. A Systematic Review Of Measures Of End-Of-Life Care And Its Outcomes. Health Serv Res; 42:1848-70.
Pan, C., Morrison, R.S., Ness, J., Fugh-Berman, A., Leipzig, R.M.,2001. Complementary And Alternative Medicine In The Management Of Pain, Dyspnea, And Nausea And Vomiting Near The End Of Life. A Systematic Review. J Pain Symptom Manage. Vol. 20: pp. 374-87.
Payne, M., 2006. Social objectives in cancer care: the example of palliative day care, European Journal of Cancer Care. Vol. 15, issue 5, pp 440-447.
Penrod,J.D., Deb P., & Luhrs, C., 2006. Cost And Utilization Outcomes Of Patients Receiving Hospital-Based Palliative Care Consultation. J Palliat Med, 9:855-860.
Randolph, J.J 2009, A guide to writing the dissertation literature review, Walden University, 2009.
Ringdal, G.I., Jordhøy, M.S., & Kaasa, S. 2002. Family Satisfaction with End-Of-Life Care For Cancer Patients In A Cluster Randomized Trial. J Pain Symptom Manage; Vol. 24, pp: 53 – 63.
Ringdal, G.I., Ringdal, K., Jordhoy, M. S, Ahlner-Elmqvist, M., Jannert, M., & Kaasa, S. 2004. Health-Related Quality Of Life (HRQOL) In Family Members of Cancer Victims: Results From A Longitudinal Intervention Study In Norway And Sweden. Palliat Med. Vol.18, pp:100-20.
Salisbury, C., Bosanquet, N., Wilkinson, E., Franks, P, Kite, S., & Lorentzon, M.1999. The Impact Of Different Models Of Specialist Palliative Care On Patient’s Quality Of Life: A Systematic Literature Review. Palliative Medicine; 13: 3-17.
Schofield, P., 2003. A Pilot Study into the Use of a Multi-Sensory Environment (Snoezelen) Within A Palliative Day-Care Setting, International Journal Of Nursing, Vol. 8, No. 3, pp 124-129.
Singer, P.A., Martin, D.K., & Kelner. M. 1999. Quality End-Of-Life Care: Patients’ Perspectives. JAMA; 281:163-8.
Slater, A., & Freeman, E. 2004. Patients’ Views of Using An Outcome Measure In Palliative Day Care: A Focus Group Study, International Journal Of Palliative Nursing, Vol 10, No 7, pp: 342-351.
Scottish Intercollegiate Guidelines Network. 2009, Systematic literature review. Web.
Solano, J.P., Gomes, B., & Higginson, I.J., 2006. A comparison of symptom prevalence in far advanced cancer, aids, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage; 31:58-69.
Song, M.K. 2005. Effects of End-Of-Life Discussions on Patients’ Affective Outcomes, Nurse Outlook; 52: 118-25.
Sörensen, S., Pinquart, M., & Duberstein, P. 2002. How Effective Are Interventions With Caregivers? An Updated Meta-Analysis. Gerontologist. Vol. 42, pp:356-72.
Taylor, D., 2009, The literature review: A few tips on conducting it, University of Toronto, Health Sciences Writing Centre, Web.
Windham, B.G., Bennett, R.G., & Gottlieb, S. 2003. Care Management Interventions For Older Patients with Congestive Heart Failure. Am J Manag Care. Vol. 9,pp: 447-59.
Woolliams, M, W., K Butcher & Pye, J,.2009. Be more practical: A practical guide for health and social care students. Oxford: Oxford Brookes University.