To our knowledge, this is the first nationwide study to explore the overall situation of facility-based palliative care in Thailand. Specifically, this study investigates how palliative care provision systems have been arranged in hospitals and whether they affect the process of care, which can enhance the quality of life of patients.
The results of this study indicate that the sufficiency and competency of the medical staff and hospitals’ nonmedical structure regarding palliative care are associated with the process concerning good death, including the response to physical and psychological needs, effective communication and respect to patients.
Staffing in palliative care has been found to be associated with better quality of care. Hospitals with more availability of medical staff can provide consistent care and are more responsive to palliative care patients’ needs [32-33]. In this study, doctors and nurses are the key staff members that contribute to the palliative care process. In addition to sufficiency, the competency of palliative care staff is crucial for the quality of palliative care provision. The number of doctors and number of nurses who had taken an intensive palliative care course was found to have a significant impact on the three aspects of the care process either directly or indirectly through the amount of time that the doctor spent with a patient. Spending more time with patients enables doctors to build a curative relationship and foster rapport, which demonstrates empathy and allows patients to express their psychosocial concerns . This finding is supported by recent studies [35-39] showing that doctors spending more time discussing information about disease or treatment guidelines in prognostic conversations would give patients greater understanding about their illness and treatment options.
Although the time nurses spend with patients is not significantly associated with the process of care, palliative care nurses generally spend more time with patients and their families than other health professionals do [40-41]. In addition, the interactions between nurses and patients are more informal than those between patients and doctors. Palliative care nurses play the main roles in individualized care , detailed communication about treatment  and facilitation of patients’ decision making regarding their end of life. The direct influences of the number of palliative care-trained nurses on effective communication and respect for patients imply the importance of the nonclinical functions of nurses in care practices that need to be strengthened in the context of palliative care.
These findings emphasize the importance of knowledge and skills specific to palliative care that improve the competency of medical staff in response to patient needs, leading to having end-of-life care discussions and planning with patients and families. However, the descriptive statistics from this study show that only 10% of participating hospitals had at least one doctor and 50% had at least one nurse who had received at least one month of training through an intensive course on palliative care. This finding confirms that palliative care training for both doctors and nurses through existing curricula in Thailand are still not adequate, as previously reported [1,6]. Therefore, promoting intensive training among medical staff should be considered a priority for the improvement of palliative care quality in the country. Given the differences in the detailed functions of doctors and nurses, palliative care courses could be designed specifically for different medical professions to optimize the knowledge and skills obtained.
Although we found clear differences in some structural components in terms of the variety of medical professions in the multidisciplinary team, availability of medical equipment and availability of medication for palliative care patients across hospitals with different levels of capacity, the associations between these medically related components and the process of care were not significant. On the other hand, nonmedical components such as availability of relaxation equipment, allocation of specific areas for palliative care patients and research in palliative care appear to be related to the process concerning good death. These managerial structure variables could imply how much a hospital is capable of and gives value to palliative care provision.
In the palliative care context, relaxation equipment such as music and prayer recordings have been found to reduce pain while promoting relaxation and relieving anxiety and depression in patients [44-46]. In the predominantly Buddhist Thai society, patients and families facing the end-of-life stage of disease are likely to listen to Dharmic recordings and read Dharmic books. It is believed that patients and their families can learn to accept, prepare and plan as they make the decision to discontinue invasive treatments and unnecessary life-prolonging procedures. Thai society remains largely based upon religious guidelines; hence, religious activities for followers of different religions, such as prayers, Quran reading, and anointing, are commonly observed with the presence of clergymen or Buddhist monks in hospitals . Religious patients can then cope with the physical, psychological and spiritual effects of the final stage of life. These practices can lead to good death [48-49]. Having a variety of relaxation equipment may indicate that hospitals’ preparedness extends beyond physical and psychosocial care to spiritual care and respect for patients’ dignity. This explains the relationship between the variety of relaxation equipment and all three aspects of the process concerning good death.
The allocation of specific areas to serve palliative care patients can lead to a better process of care, particularly for the communication of sensitive issues . Thai medical practitioners are expected to follow the guidelines for palliative care communication, particularly when delivering bad news and discussing care planning with patients and family members [11, 51]. These are sensitive issues that might have psychological impacts on patients whose conditions are clinically unstable or made complex by the symptoms of disease. Staying in an organized, private zone with those whom patients are familiar with would have positive effects on patient quality of life . The significant association between having a designated area specifically for palliative care and effective communication, in one way, suggests that the challenges to palliative care communication could be overcome if hospitals take into consideration the necessity of physical space for patients and their family caregivers.
Research in palliative care might lead to practice guidelines, quality indicators or specific tools for better care performance [53-54]. Hospitals that have conducted research in palliative care were found to have a better quality of care process in terms of response to patients’ needs and effective communication. As mentioned earlier, most hospitals in Thailand reported following guidelines developed in their specific facility , which implies a wider interest in improving the quality of palliative care at the facility level. However, the number of hospitals that have experience in conducting research, as found from this study, is quite limited. Among the palliative care studies that have been performed so far, most are descriptive, and there is little intervention research related to the promotion of quality of life among patients and their families . Although this study was not an intervention study, it confirms the significance of research at the facility level for the improvement of the palliative care process.
In this study, setting, we cannot capture the differences in the quality of the palliative care process concerning good death between hospitals with higher and lower medical capacity. This might be due to the nature of palliative care, which relies more on psycho-social-spiritual aspects of care in which patients’ physical conditions can be managed well even with less advanced medical equipment and medication. It should be noted that both financial and technical support are vital for the investment in improving human resources, medical and nonmedical equipment, the physical environment and other related resources of care. As such, hospitals’ managerial philosophy and organizational culture would majorly contribute to this matter. For future studies, hospitals’ structural characteristics, particularly managerial and cultural aspects of healthcare organizations, should be included to systematically explain more details of palliative care quality management.
This study employs Donabedian’s S-P-O framework by assuming that the quality of structure and process of palliative care would lead to the ultimate outcome of good death. However, no actual outcome data were directly collected in this study for two main reasons. First, palliative care outcomes have been measured in different ways, mostly in terms of satisfaction of care provided, not in terms of good death and the dying process. There is no standard quantification of palliative care outcomes that we can observe in the study setting. Second, this is a cross-sectional study, so the interpretation of causal linkages from structure to process to outcome, according to the theory, is limited. However, the structure and process measures of, for example, the availability and competency of human resources, the availability of pain killers, psychosocial support for patients and families and support for shared decision making are among the indicators for the Quality of Good Death Index . We believe that the study results indicate what structural components are essential for better care processes and how palliative care provision should be designed at the facility level.
Having an organization as a unit of analysis generally requires objective measurement of organizational-level variables. Thailand is in an active phase of developing guidelines and quality standards for palliative care [9, 56]; however, as mentioned earlier, hospitals apply different performance indicators. Therefore, we used objectively observed variables that can be commonly obtained from any hospital to construct the measurement models for the three aspects of care. Accordingly, these data allowed us to conduct a quantitative evaluation of the overall situation and a comparison of palliative care provision performance across medical facilities nationwide despite a standard quality measurement not yet being available.
This study has some limitations that need to be addressed. First, the study setting is limited to only institutional care, which mostly involves patients approaching the end of life. Even though medically related structural components and staff specialization were not found to be significant predictors of the palliative care process in this study, we cannot conclude that they are not important. Palliative patients in different stages of disease progression may have different needs for the structure and process of care. The specific needs of patients in stages of different disease progression could be further explored. Second, this study uses objective measurement to obtain the data that any hospital can provide; however, it fully relies on primary data collection using questionnaires self-administered by hospital representatives. Some information may be obtained from estimations and thus has the possibility of response bias. Facility- and national-level databases that include standard indicators for palliative care should be developed to facilitate potential research for quality improvement. Third, the structure of care is operationalized using directly observable components such as numbers, variety and presence of human and physical resources, while organizational context such as managerial styles, culture, leadership, policies and other organizational-level factors that might affect how palliative care is managed and provided are not included. This limits the interpretation of the study findings in terms of how a medical facility should manage to obtain a better quality of palliative care. Future studies on the role of structural characteristics of hospitals in determining the quality of palliative care are encouraged.