3.3. Phase 2: Exploratory Phase
Together with other Swiss healthcare facilities, we evaluated the usefulness of ‘SENS’ in the acute hospital and outpatient PC setting.
A formal evaluation among professionals revealed important feedback. The majority (49.1%) of the respondents had a nursing background (Table 3
), working either in a specialized hospital-based or home care service, with a considerable amount of PC experience.
Overall, ‘SENS’ was used by the respondents both in the early PC phase and in the dying phase, respectively (72.2%). Respondents used ‘SENS’ mainly within the interprofessional team context, and it was rated most helpful for providing an overview of current problems and individual expectations, as well as for interprofessional collaboration and coordination. The vast majority of the respondents (81.5%) felt that the active participation of patients and family carers in defining a common care plan was well supported by the ‘SENS’-structure. Although professionals need certain training to lead the conversation with the patient according to the ‘SENS’-structure, most participants (87%) had good experience with the use of ‘SENS’. Specifically, when patients do not want to address the issue of dying and death, some professionals felt that it was challenging to use ‘SENS’ with all its components.
Feedback from professionals (nurses and physicians) and patients as part of annual medical quality assurance audits, as well as responses from the survey, revealed benefits in the following four main areas:
Firstly, the ‘SENS’-structured initial assessment seemed to help patients and families to gain a systematic overview of future challenges. ‘SENS’ encouraged them to talk about these—often very personal—worries. Often, a medical diagnosis-driven approach was in the foreground; therefore, some patients seemed challenged by focusing early on non-medical topics and analyzing their situation systematically.
We found that all four areas of ‘SENS’ were equally relevant. ‘SENS’ provided an initial overview which could then be assessed in greater detail using validated assessment tools for specific symptoms whenever appropriate. The structure seemed to be evenly helpful in ePC, in more advanced and complex palliative situations and the dying phase. The distinction between managing symptoms and discussing end-of-life decisions was obvious to clinicians. In some documented conversations, the difference between the “N” = network (who belongs to the social network and which professional systems do the patients and families have in place) and the second “S” = support for the carers was not always clear. We concluded that “support” as term alone may be misinterpreted and added “for the carers” to specifically focus on the assessment of carer or family burden.
These findings were supported by the results of the online survey, in which the majority of the participants felt that all four areas covered always or almost always the situation of patients. This was particularly clear in the themes ‘Symptom management’ (94.6%), ‘End-of-life decisions’ (89.3%), and ‘Network-organization’ (78.6%). Probably the theme ‘Support for the carer’ still needs more refinement since 50.9% of the survey participants felt that it covered the support for patients but not the support needs for the burdened carers. It offered a needs-based approach for multifaceted situations driven by concrete problems of daily life, while utilizing resources of patients.
From the perspective of health care professionals, ‘SENS’ has been independently used and proven to be helpful in clinical practice [30
] for structuring the assessment of the main concerns. It appeared to be helpful as a “short and simple” enough assessment structure for general and specialist PC settings [19
], such as hospitals (inpatient PC, consultancy services), nursing homes, or primary care settings.
from clinical practice, we know that ‘SENS’ was often used in interprofessional rounds. It showed that ‘SENS’ served as a useful structure to develop a care plan together with patients, guiding the setting of goals of care, expectations, prioritization, responsibility, planning, and allocation of resources and financial reimbursement. It also supported the collaboration within the interprofessional team (Table 4
Clear distribution of tasks and responsibilities within the interprofessional team, including timelines and changes of priorities, could be outlined from the beginning of the PC intervention based on ‘SENS’. As an example: if physical symptoms were initially in the foreground, close cooperation between the medical and nursing staff was necessary. The focus could later shift to discussing the future place of care, including network organization and emergency planning, for which the social worker and mobile PC teams may have taken the lead.
Thirdly, ‘SENS’ structured the evaluation of care, which allowed a better judgment of the complexity within a particular area. Based on a common language, ‘SENS’ offered an effective way to prepare and document a problem-oriented family conference in which the interprofessional team members each had their specific tasks. In addition, ‘SENS’ helped to thematically structure case discussions and critical review.
‘SENS’ has lately been officially recommended as a structure for professional education and reimbursement. The areas of ‘SENS’ can be weighted depending on the target of professional education (physicians, nurses, social workers, etc.), as shown in postgraduate basic and specialist PC training programs in Switzerland [32
]. At the same time, it can ensure that all essential topics are equally covered. Since 2015, the ‘SENS’ structure was officially implemented in Swiss medical schools by the publication of Eychmueller et al. [33
] as recommended teaching material. In addition, ‘SENS’ was adopted as a basic assessment-structure triggering the comprehensive diagnosis related groups (DRG)-codes for complex PC treatment within the SWISS Health Care System [34