Browsing by Author "Krause, Stephanie"

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    Open Access
    A retrospective cross-sectional analysis of palliative care needs and interventions in patients with cervical cancer in a palliative care unit in Soweto, Johannesburg
    (2023) Sobekwa, Mfanelo; Krause, Stephanie
    Introduction Cervical cancer is the second most prevalent cancer among women in South Africa. Little published research is available on the pain syndromes associated with cervical cancer and on the specific spiritual issues in patients with cervical cancer. Aim The aim of this study was to describe and provide an analysis of Palliative Care and total pain needs in patients diagnosed with cervical cancer in two Gauteng hospitals. Objectives The objectives were to determine the physical, psycho-social, and spiritual symptom burden of cervical cancer patients and assess for any correlation between a number of these symptoms and other significant variables. Methodology This study was a retrospective data analysis of 138 records of confirmed cervical cancer patients enrolled at the centre for palliative care at Chris Hani Baragwanath Academic Hospital and Sebokeng Regional Hospital. The data was analysed using SPSS version 10. Categorical variables were summarised using cross tabulation and reporting using Pearson Chi-squared test to determine if there were non-random associations between two independent categorical variables. To compare groups, means, and standard deviations with t-tests for normally distributed variables, medians, and interquartile ranges were also used. All the tests were twotailed and a p-value of less than 0.05 was considered statistically significant. The Confidence Intervals (CIs) were calculated at a 95% confidence level. Results The mean age was 50.53 (range 26-84), with 49% being below age 50 and 76% below age 60. A proportion of 41.7% of patients had an ECOG Performance status score of 0-1 which meant that they had no to little impact on the performance of daily activities. The majority of patients' performance was significantly impacted (58.3%) by their illness, bearing an ECOG score of 2 2 P a g e and above. A majority of patients (80%) reported severe to worst pain, with only 10.8% having expressed no pain at all and 2% reporting to have mild pain. The most commonly expressed distressing physical symptoms were lower abdominal pain at 75%, followed by constipation at 48%, and lower back pain at 30%. Just above two-thirds (70%) of the patients were found to be at advanced stage of the disease presenting at FIGO stage III or IV. Iron deficiency anaemia was found to be another significant clinical condition present in 80.6% of patients with a mean haemoglobin of 8.51. The most prevalent comorbid medical condition amongst this group of patients was HIV (52%) with hypertension (36%) as the second most prevalent. The data showed that 93% of the patients considered themselves spiritual, with 86% wanting a stronger connection with God or a higher being. Only 31% felt abandoned by God and 19% by their spiritual community. Further analysis revealed that 67% of patients did not feel that their illness was a punishment from a higher being and just over half of the patients (53%) felt a need to be forgiven by God for past transgressions. 81% of patients expressed a need for spiritual support as part of their clinical care. 92% of patients expressed to be worried about their illness with 87.7% being able to share how they feel with family or friends. 82.6% experienced peace despite their challenges, with only 10.9% not being at peace.93.5% still felt that life was worthwhile despite having cervical cancer. There was a positive correlation between ECOG & worry and ECOG & peace and a negative correlation between ECOG & being able to share. A negative correlation between worry and peace and a positive correlation between being able to share & peace, help for future planning & life worthwhile, information & being able to share and information and peace. Feelings of punishment seem to increase the feeling of being abandoned by a higher being, and a need for a stronger connection to a higher being emerged as a central connecting theme. Conclusion This research study highlighted that, indeed, cervical cancer patients have a number of significant palliative care needs that need to be paid attention to when treating them. These needs are multi-dimensional in nature, and some may be complex. Managing these patients requires an interdisciplinary approach and the involvement of multiple team members (including family) to respond to their needs adequately
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    An evaluation of implementing integrated palliative care at an academic teaching hospital
    (2025) Krause, Stephanie; Gwyther, Elizabeth; Olivier, Jill
    Palliative Care is presently being integrated within an academic teaching hospital in South Africa. The World Health Organisation has stated that palliative care is an ethical responsibility of health systems. However, despite a National Policy Framework and Strategy for Palliative Care, there is a limited funding allocation for Palliative Care in South Africa. South Africa experiences distinctive disease-related and contextual challenges that influence the normalisation of palliative care practice. Consequently, specific palliative care implementation strategies have been devised in response to the constraints of limited resources to suit this context. This research aims to evaluate and describe the effectiveness of the current integration strategies for Palliative Care within the South African Academic Teaching Hospital context, specifically Groote Schuur Hospital. The author conducted a descriptive and explorative study to describe and evaluate how and why these strategies contributed to integrating palliative care within the academic teaching hospital. The author drew from Valentijn's theory on integration to conceptualise the domains and extent of palliative care integration. Valentijn’s theory emphasises the interlink between the normative and functional aspects of integration and, furthermore, the extent of integration, which can be at a clinical, professional, organisational or systems level. The interlinking of these aspects is imperative in palliative care integration. Palliative care is also a complex intervention; therefore, understanding the context in which this complex intervention is being integrated is core to understanding how and why these interventions work. The author provides an in-depth description of the context to explain why palliative care integration worked or not. The author is an embedded researcher and was involved in developing and evaluating the strategies. The concerns of bias and trustworthiness of this research were ensured by using triangulation of data, member checking and including co-strategists from the implementation of these strategies in the evaluations. In chapter 1, the author provides background information, the substantive relevance and an overview of the research. Chapter 2 is a narrative literature review that provides an overview of implementation research, integration research and PC research convergence to beTer understand PC integration and implementation. The following chapters use interdisciplinary mixed-method evaluations conducted in three parallel phases. In chapter 3 the author describes the hospital's specific context in relation to the integration of palliative care. Chapter 3 is a mixed-method study to explore contextual factors influencing the integration or lack thereof in an academic teaching hospital. This approach assisted in expanding on the contextual phenomena, corroborating findings and explaining the interconnectedness between the different levels. Chapter 4 describes a sub-study to evaluate a structural change (introducing a specialised palliative care team). It is a mixed methods sequential study that evaluates and describes how the service is integrated into GSH. Chapter 5. A mixed method parallel study describes the evaluation of an educational approach (training oncology trainees). Chapter 6, a qualitative study, describes the evaluation of the effect of integrating PC into oncology training on PC integration. Chapter 7 describes the evaluation of a change in hospital processes (quality improvement in the care of patients with pancreatic adenocarcinoma). Chapter 7 is a mixed method sequential design and demonstrates how a quality improvement cycle contributed to palliative care integration. In Chapter 8, the strategies were analysed to assess their effectiveness in relation to integration and to identify the mechanisms that facilitate integration. The chapter draws conclusions from the research and makes recommendations on how to proceed with the integration of PC identifying areas for further research. The research methodology included primary interviews (n=20), focus group discussions (n=3), secondary data analysis, training evaluations, analysis of hospital data, Palliative Care service data, and targeted document analyses to expand and corroborate findings. The qualitative data were analysed using thematic analyses (inductive and deductive) using NVIVO. Quantitative data provided descriptive statistical analyses. This research has demonstrated that a specialised Palliative Care team successfully achieved clinical integration and normalised the practice of palliative care. Over a five-year period (2017-2022), a notable increase in referrals for Palliative Care services was observed. In 2017, the hospital received 737 palliative care referrals, which grew to 931 in 2020 and further escalated to 1202 in 2022, demonstrating a statistically significant upward trajectory. This increased reach extended initially from only medical wards but now includes include Outpatient services and Intensive Care Unit (ICU) care. The reason for the extent of the strategy is linked to the mechanism of observing palliative care being practised, which challenged the context-specific assumptions about Palliative Care. Furthermore, professional and clinical integration were achieved when the specialised service strategically collaborated in an area with a high burden of patients, like the surgical care of pancreatic adenocarcinoma, using an interactive quality improvement strategy. This resulted in a significant increase in comprehensive care and palliative care referrals. However, an educational strategy targeting junior trainees in oncology did not yield the expected clinical or professional integration outcomes. In oncology services documentation related to Palliative Care and perceptions among decision-makers remained largely unchanged. Notably, while full organisational integration was not achieved, the presence of the specialised Palliative Care team had a substantial impact on the hospital's organisational culture, creating a ripple effect throughout the institution because it normalised palliative care within the academic teaching hospital. This research underscores the vital role of specialised Palliative Care teams in enhancing clinical integration and shaping the broader healthcare environment, prompting further exploration and strategic adjustments for future improvement. This study confirms findings from other global studies that specialised Palliative Care teams play a central role in integration within a hospital sebng and shaping the broader healthcare environment, prompting further exploration and strategic adjustments for future improvement. Even with limited resources, specialised teams contribute to the process of integrating Palliative Care due to their capacity to transform a hospital's culture in relation to palliative care. Although educational strategies are important, the focus of these strategies should be on influencing both junior and senior staff and developing a palliative care team within hospitals.
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    Open Access
    Barriers to morphine use in primary care in the Cape Town metropole
    (2023) Hofmeyr, Graeme; Krause, Stephanie; Tiffin Nicola
    Background Access to oral morphine is an essential element of palliative care services, and a useful indicator of the availability of those services. The South African National Policy Framework and Strategy on Palliative Care 2017- 2022 envisages a system in which palliative care is widely available in the primary healthcare or community setting. If this is to be achieved an analysis of the morphine use patterns withing the health system, and the development of indicators to monitor implementation are vital. Aim The aim of this research was to examine the patterns of oral, outpatient morphine prescription in public healthcare facilities within the Cape Town Metropole, and to develop methods to compare the patterns of oral morphine use between primary care facilities, district hospitals and tertiary hospitals. Setting The setting of this study is the public healthcare system in the Cape Town Metropole during the period 2016- 2018. Methods In this descriptive analysis a dataset was generated from routinely collected prescribing and outpatient headcount information to allow an analysis of morphine prescribing patterns within the Metro, and comparison both between facilities and levels of care. Results The rate of morphine prescription was much higher at the two tertiary facilities (605.2 episodes/100 000 outpatient visits) than at District Hospitals or at Primary Care (182.1 and 56.6 episodes/100 000 outpatient visits respectively. There was considerable variation between prescribing rates of facilities at the same level of care. Conclusion Access to oral morphine at the primary care level is limited and needs to be improved if South Africa is to successfully implement local and international guidelines on the provision of palliative care at the primary and community level. The ratio of morphine prescription to outpatient visits allows useful comparisons to be made between access to palliative care services at healthcare service levels and individual facilities.
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    Evaluating the outcomes of cancer patients receiving palliative care in Botswana
    (2025) Radikara, Naledi; Krause, Stephanie; Masupe, Tiny
    Botswana is an upper middle-income country in Sub-Saharan Africa that is experiencing a growing incidence of cancer and other Non-Communicable Diseases and is at the early stages of implementing Palliative Care (PC). PC has been shown to enhance the quality of life (QoL) of patients and their families, consequently improving their health outcomes. This research will emphasise the importance of PC in the Botswana health care system and aims to determine the outcomes of patients under palliative care at Princess Marina Hospital (PMH). Methods: We prospectively enrolled 53 consecutive patients with a diagnosis of metastatic and/or progressive cancer who were referred to the PC team for the first time from March 2023 to November 2023. The primary end-point was a change in symptoms and QoL from baseline to four (4) weeks as per the APCA African POS questionnaire and the ECOG PS tool. Participants were assessed initially at entry to PC services and again after 4 weeks while under PC. Results: A total of 53 participants were included in the initial assessment while 42 were included in both the initial and subsequent assessments, indicating an attrition rate of 21%. The top 5 cancers were: breast (20.8%), cervical(15.1%), prostate(9.4%), anorectal(9.4%) and oesophageal(9.4%). Symptoms occurring in at least 50% of the participants were: pain (94.3%), weakness (75.5%), nausea (58.5%), loss of appetite (64.1%), constipation (50.9%), dry mouth (69.8%), drowsiness (56.6%), poor mobility (54.7%) and worry (90.6%). The results showed that the difference was statistically significant between the two -time points for pain (z=2.707, p = 0.0068), shortness of breath (z=2.261, p=0.0238), nausea (z=3.275, p=0.0011), loss of appetite (z=2.480, p=0.0131), constipation (z=2.832, p=0.0046), drowsiness( z=3.091, p=0.0020), ability to share feelings with family and friends(z=0.701, p=0.0069) and advice to plan for the future(z=2.586, p=0.0097).Vomiting(z=0.982, p=0.326), dry mouth(z=1.466, p=0.1426) , poor mobility(z=1.922, p=1.922), feelings of worry( z= 1.127, p=0.2596), feeling that life is worthwhile(z=1.330, p=0.1835) and feeling at peace(z=1.651, p=0.0987) did not show a statistically significant difference between the before and after measurements, however, in all these domains, the difference was such that the average score was less at the subsequent assessment. Total mean scores (composite scores) for the physical and psychological symptoms were analysed between the two time periods and the difference was statistically significant (z=3.828, p=0.0001). The difference between the before and after measurements for functional status was not statistically significant (z=-0.611, p=0.542). Conclusion: Patients with advanced cancer have a high symptom burden which affects their QoL. A PC approach appears to be effective in improving symptoms and QoL of patients with advanced cancer.
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    Evaluation of the acceptability and validity of the Serious Illness Conversation Guide in oncology patients in South Africa
    (2025) Burger, Henriette; Krause, Stephanie
    Background: Advance care planning (ACP) is the process through which a health care professional (HCP) guides a patient with a life-threatening illness to better understand their disease and to make value-concordant decisions for their future medical care including their end-of-life (EOL) care. The Serious Illness Conversation Guide (SICG, Ariadne Labs 2017) was developed and validated as a structured guide for HCPs when having ACP conversations with patients. Decision-making near the end of life is influenced by many factors including health status, socio-economic status, culture, ethnicity, and decisional control preferences. To our knowledge no study has explored the acceptability and validity of the SICG (Ariadne Labs) in cancer patients in South Africa (SA). Objectives: The aims of this study are to explore the local acceptability and validity of an internationally validated serious illness conversation guide for use in advance care planning conversations in South African patients with advanced cancer. Methods: A mixed-methods study design was used to explore the local acceptability and validity of the SICG using a survey and focus-group discussions (FGD) with healthcare professionals. In the quantitative survey each participant was asked to classify the local acceptability of each SICG prompt according to a 3-tiered system. Further survey questions assessed their practice settings, patterns of ACP, perceptions of cross-cultural acceptability of prompts, and the need for additional questions in the SICG. The FGD transcripts were qualitatively analysed using both inductive and deductive thematic analysis to reflect the research question as well as emerging themes. Results: Focus group discussions (FGD) were conducted with 17 healthcare workers during 2021. Analysis of the survey and FGD data suggests that several SICG prompt are not cross- culturally acceptable in their current state in the South African setting. Emerging factors influencing acceptability in the SA oncology context included poor illness understanding, the use of complex and incongruent language, health system limitations, the role of the family, and the role of belief systems and culture. Conclusion: The findings of this study can be used to adapt the Serious Illness Conversation Guide for the South African population to increase uptake of ACP and improve understanding of EOL care preferences for South Africans.
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    The use of traditional herbal medicines among palliative care patients at Mulanje Mission Hospital, Malawi
    (2019) Chisaka, Joseph Wangisani; Krause, Stephanie; Bates, Maya Jane
    Background: The prevalence of use of traditional medicines by patients receiving palliative care is poorly documented. In 2002, the World Health Organisation estimated about 4 billion people (80% of the world’s population) used traditional medicines for some aspect of primary healthcare, with 90% of users living in low and middle income countries. Studies in Africa have shown that patients on palliative care are more likely to use traditional medicines especially after the diagnosis of cancer. This study describes the prevalence of and reasons for TM use amongst PC patients and also explores the common herbs used by this population. Methodology: A mixed method descriptive cross sectional study design was used including the following: questionnaire administered to patients attending palliative care clinic and focus group discussions with palliative care patients. Results: 60.4% of palliative care patients (n = 96; males = 53%) reported use of traditional herbal medicines. The majority of survey participants had the diagnosis of cancer (94%; n = 90) and HIV (89%; n = 85). Traditional herbal medicine use was common in participants who had the following symptoms: diarrhoea 83%, anorexia 63%, pain 61% etc. Traditional medicine use was not associated with age, gender, education, occupation, distance from hospital, diagnosis or symptom. 62% of the participants who used herbal medicines did not know the herbs they were taking. Kigelia Africana, Moringa oleifera, Cyphostema sp, and Strychnos innocua were the common herbs used. Cultural practices, limitations of conventional health system and credibility of traditional healers were the main reasons for using traditional herbal medicines. Conclusion: Use of traditional herbal medicines is high among patients receiving palliative care at Mulanje Mission hospital mainly for symptom management and cancer. Further research is needed to investigate effectiveness of identified herbs and also assess their potential herb-drug interactions. Ongoing work including liaison with traditional healers would assist to formulate effective local palliative care management programs that are sensitive to traditional medicine practices.