Palliative Care Eligibility, Symptom Burden, and Quality-of-Life Ratings in Nursing Home Residents

Disability and Place of Death in Older Americans: The Moderating Role of Household Wealth

CONTEXT

Home-based deaths are increasing, yet, how wealth influences where people die in the presence of disability remains unknown.

OBJECTIVE

To examine place of death by help with (instrumental) activities of daily living (I/ADLs) at the end of life (EOL) and the modifying role of wealth.

METHODS

Retrospective study of decedents from the Health and Retirement Study (n = 13,210). The exposure was intensity of help with I/ADLs at the EOL (no help/ lower intensity/higher intensity). The outcome was place of death (hospital/nursing home/home). Household wealth was an effect modifier with six categories: ≤$0, first-fifth quintile. Covariates included age, gender, race, marital status at the EOL, last place of residence, and receipt of hospice care. We used multinomial logit regression models with estimates reported as average marginal effects (AMEs).

RESULTS

Mean age was 79.8 years; 53.2% were female. In the adjusted models, compared to not receiving help at EOL, receiving higher-intensity help was associated with a lower probability of dying in a hospital (AME = -3.8 percentage points (pp), 95% CI = -6.3 to -1.3) and a higher probability of dying at home (AME = 3.6 pp, 95% CI = 1.4-5.7). Associations were most pronounced among decedents in the top two wealth quintiles; older adults who received higher-intensity help had a lower probability of dying in a hospital (AME = -9.0 pp, 95% CI = -14.8 to -3.1), and a higher probability of dying at home (AME = 8.4 pp, 95% CI = 3.8-13.0).

CONCLUSION

Receiving higher intensity of help with I/ADLs was associated with lower likelihood of dying in a hospital, and higher likelihood of dying at home, particularly among older adults with greater wealth.

Being Seen as a Unique Person is Essential in Palliative Care at Home and Nursing Homes: A Qualitative Study With Patients and Relatives

CONTEXT

Incorporation of a palliative care approach is increasingly needed in primary care and nursing home care because most people with a life-limiting illness or frailty live there.

OBJECTIVES

To explore patients' and relatives' experiences of palliative care at home and in nursing homes.

METHODS

Generic qualitative research in a purposive sample of patients with an estimated life expectancy of <1 year, receiving care at home or in a nursing home, and their relatives. Data is collected through semi-structured interviews and thematically analyzed by a multidisciplinary research team.

RESULTS

Seven patients and five relatives participated. Three essential elements of palliative care and their contributing factors emerged: 1) be seen (personal attention, alignment to who the patient is as a person, and feeling connected) 2) information needs (illness trajectory and multidimensional symptoms and concerns, and 3) ensuring continuity (single point of contact, availability of HCPs, and coordination of care). Patients and relatives experienced loss of control and safety if these essentials were not met, which depended largely on the practices of the individual health care professional.

CONCLUSION

In both primary care and nursing home care, patients and relatives expressed the same essential elements of palliative care. They emphasized the importance of being recognized as a unique person beyond their patient status, receiving honest and clear information aligned with their preferences, and having care organized to ensure continuity. Adequate competence and skills are needed, together with a care organization that enables continuity to provide safe and person-centered care.

A Process Evaluation of a Palliative Care Social Work Intervention for Cancer Patients in Skilled Nursing Facilities

Background: Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care social work intervention that aims to improve delivery of goal-concordant care for hospitalized older adults with cancer discharged to skilled nursing facilities. Objective: Explore processes through which ALIGN may improve delivery of goal-concordant care to substantiate the conceptual model grounding the intervention and to inform mechanistic hypotheses of how the intervention might be effective. Design: A process evaluation triangulating findings from patient and caregiver interviews with a matrix analysis of ALIGN social worker notes. Setting/Participants: Patients (n = 6) and caregivers (n = 13) who participated in a single-arm pilot study of ALIGN in the United States and 113 intervention notes (n = 18 patients) written by 2 ALIGN social workers. Measurement: Qualitative thematic content analysis Results: Themes included the following: (1) ALIGN helped reconcile participants' misaligned expectations of rehabilitation with the reality of the patient's progressive illness; (2) ALIGN helped participants manage uncertainty and stress about forthcoming medical decision making; (3) the longitudinal nature of ALIGN allowed for iterative value-based goals of care discussions during a time when patients were changing their focus of treatment; and (4) ALIGN activated participants to advocate for their needs. Conclusions: ALIGN offers support in prognostic understanding, communication, and decision making during a pivotal time when patient and caregivers' goals have not been met and they are reassessing priorities. A larger trial is needed to understand how these processes may improve the ability of participants to make value-based decisions and aide in delivery of goal-concordant care. Clinical Trial Registration Number: NCT04882111.

What are the barriers and facilitators to advance care planning with older people in long-term care facilities? A qualitative study

AIM

To explore the views and preferences for advance care planning from the perspectives of residents, family members and healthcare professionals in long-term care facilities.

DESIGN

A qualitative descriptive design.

METHODS

We conducted semi-structured interviews with 12 residents of long-term care facilities, 10 family members and 14 healthcare professionals. Data were analysed using reflexive thematic analysis. The social ecological model was used to develop implementation recommendations.

RESULTS

We constructed a conceptual model of barriers and facilitators to advance care planning in long-term care facilities, drawing upon four dominant themes from the qualitative analysis: (1) The absence of discourse on end-of-life care: a lack of cultural climate to talk about death, the unspoken agreement to avoid conversations about death, and poor awareness of palliative care may hinder advance care planning initiation; (2) Relational decision-making process is a dual factor affecting advance care planning engagement; (3) Low trust and 'unsafe' cultures: a lack of honest information sharing, risks of violating social expectations and damaging social relationships, and risks of legal consequences may hinder willingness to engage in advance care planning; (4) Meeting and respecting residents' psychosocial needs: these can be addressed by readiness assessment, initiating advance care planning in an informal and equal manner and involving social workers.

CONCLUSION

Our findings show that residents' voices were not being heard. It is necessary to identify residents' spontaneous conversation triggers, articulate the value of advance care planning in light of the family's values and preferences, and respect residents' psychosocial needs to promote advance care planning in long-term care facilities. Advance care planning may alleviate the decision-making burden of offspring in nuclear families.

IMPLICATIONS FOR CLINICAL PRACTICE

The evidence-based recommendations in this study will inform the implementation of context-specific advance care planning in Asia-Pacific regions.

PATIENT AND PUBLIC CONTRIBUTION

Patients and caregivers contributed to the interview pilot and data collection.

Improving End-of-Life Care for Nursing Home Residents Using an Interprofessional Approach

Interprofessional collaboration enhances quality end-of-life care leading to a dignified death. Hospice care uses an interdisciplinary approach to optimize quality of life and mitigate impacts of serious illness. Interventions to improve hospice care delivery have been proven to be effective, but little is known about nursing home staff preparedness, implementation of hospice education, and interprofessional communication. Research is limited on how hospice care can be implemented into the nursing home setting. The purpose of this study was to determine if education combined with a communication tool improved nursing home staff knowledge and improved communication with the hospice team. The descriptive study invited participants to take a preseminar and postseminar survey to assess end-of-life preparedness in terms of willingness, capability, and resilience. A communication tool was implemented to measure collaboration with the hospice team over 3 months. The results from this study suggest education combined with interprofessional communication improves end-of-life care.

Healthcare professionals' perceived barriers in providing palliative care in primary care and nursing homes: a survey study

Background

Palliative care in primary care and nursing home settings is becoming increasingly important. A multidimensional palliative care approach, provided by a multiprofessional team, is essential to meeting patients' and relatives' values, wishes, and needs. Factors that hamper the provision of palliative care in this context have not yet been fully explored.

Objectives

To identify the barriers to providing palliative care for patients at home or in nursing homes as perceived by healthcare professionals.

Design

Cross-sectional survey study.

Methods

A convenience sample of nurses, doctors, chaplains, and rehabilitation therapists working in primary care and at nursing homes in the Netherlands is used. The primary outcome is barriers, defined as statements with ⩾20% negative response. The survey contained 56 statements on palliative reasoning, communication, and multiprofessional collaboration. Data were analyzed using descriptive statistics.

Results

In total, 249 healthcare professionals completed the survey (66% completion rate). The main barriers identified in the provision of palliative care were the use of measurement tools (43%), consultation of an expert (31%), estimation of life expectancy (29%), and documentation in the electronic health record (21% and 37%). In primary care, mainly organizational barriers were identified, whereas in nursing homes, most barriers were related to care content. Chaplains and rehabilitation therapists perceived the most barriers.

Conclusion

In primary care and nursing homes, there are barriers to the provision of palliative care. The provision of palliative care depends on the identification of patients with palliative care needs and is influenced by individual healthcare professionals, possibilities for consultation, and the electronic health record. An unambiguous and systematic approach within the multiprofessional team is needed, which should be patient-driven and tailored to the setting.

Palliative medicine in the emergency department: symptom control and aggressive care

OBJECTIVES

Identifying the prevalence of palliative care (PC) needs among patients who die at the emergency department (ED) and to assess symptom control and aggressiveness of care.

METHODS

We conducted a decedent cohort study of adults deceased at the ED of a Portuguese teaching hospital in 2016. PC needs were identified using the National Hospice Organization terminality criteria and comorbidities measurement by the Charlson's Index.

RESULTS

384 adults died at the ED (median age 82 (IQR 72-89) years) and 78.4% (95% CI 73.9% to 82.2%) presented PC needs. Only 3.0% (n=9) were referred to the hospital PC team. 64.5%, 38.9% and 57.5% experienced dyspnoea, pain and confusion, respectively. Dyspnoea was commonly medicated (92%), against 56% for pain and 8% for confusion. Only 6.3% of the patients were spared from aggressive interventions, namely blood collection (86.0%) or intravenous fluid therapy (63.5%). The burden of aggressive interventions was similar between those with or without withhold cardiopulmonary resuscitation order (median 3 (2-4) vs 3 (2-5)), p=0.082.

CONCLUSIONS

Nearly four out of five adults who died at the ED had PC needs at the time of admission. Most experienced poor symptom control and care aggressiveness in their last hours of life and were mostly unknown to the PC team. The findings urge improvements in the care provided to patients with PC needs at the ED, focusing on patient well-being and increased PC referral.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family

Background

Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL).

Objective

To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405).

Methods

Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424).

Results

Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001).

Conclusions

Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.

Identifying Nursing Home Residents with Unmet Palliative Care Needs: A Systematic Review of Screening Tool Measurement Properties

OBJECTIVES

Despite common use of palliative care screening tools in other settings, the performance of these tools in the nursing home has not been well established; therefore, the purpose of this review is to (1) identify palliative care screening tools validated for nursing home residents and (2) critically appraise, compare, and summarize the quality of measurement properties.

DESIGN

Systematic review of measurement properties consistent with Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

SETTINGS AND PARTICIPANTS

Embase (Ovid), MEDLINE (PubMed), CINAHL (EBSCO), and PsycINFO (Ovid) were searched from inception to May 2022. Studies that (1) reported the development or evaluation of a palliative care screening tool and (2) sampled older adults living in a nursing home were included.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias.

RESULTS

We identified only 1 palliative care screening tool meeting COSMIN criteria, the NECesidades Paliativas (NEC-PAL, equivalent to palliative needs in English), but evidence for use with nursing home residents was of low quality. The NEC-PAL lacked robust testing of measurement properties such as reliability, sensitivity, and specificity in the nursing home setting. Construct validity through hypothesis testing was adequate but only reported in 1 study. Consequently, there is insufficient evidence to guide practice. Broadening the criteria further, this review reports on 3 additional palliative care screening tools identified during the search and screening process but which were excluded during full-text review for various reasons.

CONCLUSION AND IMPLICATIONS

Given the unique care environment of nursing homes, we recommend future studies to validate available tools and develop new instruments specifically designed for nursing home use. In the meantime, we recommend that clinicians consider the evidence presented here and choose a screening instrument that best meets their needs.

Pilot Trial of a Social Work Intervention to Provide Palliative Care for Adults with Cancer in Skilled Nursing Facilities

Background: Hospitalized patients with cancer and their caregivers discharged to skilled nursing facilities (SNFs) have unmet palliative care needs. Objective: To determine feasibility and acceptability of Assessing and Listening to Individual Goals and Needs (ALIGN), a palliative care social worker (PCSW) intervention, for older adults and their caregivers in SNFs. Design: Single-arm, single-site pilot study. Predefined feasibility goals were >70% intervention completion and study retention rates (postintervention outcomes completed at one week). Setting/Subjects: Twenty-three patients with cancer and their 21 caregivers discharged to 12 SNFs posthospitalization. Measurements: Primary outcomes were feasibility and acceptability. Exploratory patient and caregiver-reported outcomes, including goals of care were collected at baseline and one week postintervention. Health care utilization, mortality, and hospice utilization was collected at the six-month follow-up. Results: Of 73 patients screened, 35 (48%) were eligible and 23 (66%) patients and 21 caregivers enrolled. Eighteen (78%) patients completed the intervention and 10 (44%) patients and 13 (62%) caregivers provided follow-up outcomes. Average age of patients was 73, and 19 (83%) had stage III or IV cancer. Average age of caregivers was 55. Eight (44%) patients' preferences changed to prefer less aggressive care. Nineteen (83%) patients died during or shortly after intervention completion. Qualitative feedback from participant and SNF staff interviews supported high acceptability. PCSW involvement increased illness understanding and patient engagement with advance care planning. SNF staff valued increased palliative support. Conclusions: Intervention completion was >70%, however, not study retention due to higher-than-expected mortality. Future study should account for high mortality and examine whether ALIGN can better prepare surrogate decision makers and enhance the ability of SNFs to address changing goals of care. Clinical Trial Registration Number NCT04882111.

Assessing Technical Feasibility and Acceptability of Telehealth Palliative Care in Nursing Homes

Background

Over two-thirds of nursing home (NH) residents are eligible for palliative care (PC), yet few receive it, particularly outside of hospice. Little is known about the technical feasibility and acceptability of using telehealth for PC consultations in NHs.

Objective

To determine the technical feasibility and acceptability of PC telehealth for NH residents seen by a PC team in the hospital in the previous 30 days.

Design

Mixed methods study including data collection from field observations, focus groups about the telehealth experience with content analysis, and a web-based survey about technical feasibility and acceptability.

Sample and Approach

Eighteen participants (six PC-eligible NH residents, one PC physician, five family members, six NH nurses) were recruited in 2016 to participate in one of six PC video visits followed by a video-based focus group and web-based survey.

Results

All participants were comfortable with the PC video visit format, believed it could improve communication and care coordination, and reported they could see themselves using telehealth in the near future. For technical feasibility, audio quality was rated mostly good/very good (71%) and visual quality was rated fair (50%).

Conclusions

PC video visits are technically feasible and acceptable to NH residents, families, and staff, representing an innovative and relatively low-cost opportunity to improve access to needed NH-based PC services. Assessing stakeholder perspectives on the use of this technology can help inform the selection of the proper telehealth platform to meet the clinical and infrastructure needs, as well as protocol modifications required before testing in a larger trial.

Impact of Behavioral Nudges on the Quality of Serious Illness Conversations Among Patients With Cancer: Secondary Analysis of a Randomized Controlled Trial

PURPOSE

Serious Illness Conversations (SICs) are structured conversations between clinicians and patients about prognosis, treatment goals, and end-of-life preferences. Although behavioral interventions may prompt earlier or more frequent SICs, their impact on the quality of SICs is unclear.

METHODS

This was a secondary analysis of a randomized clinical trial (NCT03984773) among 78 clinicians and 14,607 patients with cancer testing the impact of an automated mortality prediction with behavioral nudges to clinicians to prompt more SICs. We analyzed 318 randomly selected SICs matched 1:1 by clinicians (159 control and 159 intervention) to compare the quality of intervention vs. control conversations using a validated codebook. Comprehensiveness of SIC documentation was used as a measure of quality, with higher integer numbers of documented conversation domains corresponding to higher quality conversations. A conversation was classified as high-quality if its score was ≥ 8 of a maximum of 10. Using a noninferiority design, mixed effects regression models with clinician-level random effects were used to assess SIC quality in intervention vs. control groups, concluding noninferiority if the adjusted odds ratio (aOR) was not significantly < 0.9.

RESULTS

Baseline characteristics of the control and intervention groups were similar. Intervention SICs were noninferior to control conversations (aOR 0.99; 95% CI, 0.91 to 1.09). The intervention increased the likelihood of addressing patient-clinician relationship (aOR = 1.99; 95% CI, 1.23 to 3.27; P < .01) and decreased the likelihood of addressing family involvement (aOR = 0.56; 95% CI, 0.34 to 0.90; P < .05).

CONCLUSION

A behavioral intervention that increased SIC frequency did not decrease their quality. Behavioral prompts may increase SIC frequency without sacrificing quality.

High-Quality Nursing Home and Palliative Care-One and the Same

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial

INTRODUCTION

Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care.

INTERVENTION

The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC.

OBJECTIVES

The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care.

METHODS

Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days.

CONCLUSION

This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.

The Role of the Palliative Care Registered Nurse in the Nursing Facility Setting

There is a growing recognition of significant, unmet palliative care needs in nursing facilities, yet limitations in the workforce limit access to palliative care services. Attention to palliation is particularly important when there are efforts to reduce hospitalizations to help ensure there are no unintended harms associated with treating residents in place. A specialized palliative care registered nurse (PCRN) role was developed as part of the OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical quality, and Improving Symptoms: Transforming Institutional Care) program, a federally funded project to reduce potentially avoidable hospitalizations. Working in collaboration with existing clinical staff and medical providers, the PCRN focuses on managing symptoms, advance care planning, achieving goal concordant care, and promoting quality of life. The PCRN serves as a resource for families through education and support. The PCRN also provides education and mentorship to staff to increase their comfort, knowledge, and skills with end-of-life care. The goals of this article are to provide an overview of the PCRN role and its implementation in nursing facilities and describe core functions that are transferrable to other contexts.

Developing and implementing a novel program to prepare nursing home-based geriatric nurse practitioners in primary palliative care

ABSTRACT

Current palliative care workforce projections indicate that the growing palliative care needs of older adults in US nursing homes cannot be met by specialists, leaving them vulnerable and at risk for poor end-of-life outcomes. The purpose of this article is to describe the development, implementation, and initial evaluation of a program to support primary care nursing home nurse practitioners (NPs) in palliative care. The program aimed to improve geriatric NPs' knowledge and skills related to palliative care and to provide a structured protocol for integrating palliative care encounters into NPs' practice. It comprised three phases consisting of asynchronous online learning modules, a 1-day face-to-face communication skills and patient simulation workshop, and ongoing monthly virtual meetings to support NP clinical practice. Over a 1-year period, the program was developed and implemented with 12 practicing NPs in a national organization. Through an online survey and face-to-face feedback, NPs reported satisfaction with the curriculum and expressed it as valuable to their clinical practice. Future work will focus on sustaining implementation of the program, measuring patient level outcomes, and refining the curriculum based on NP feedback.

POLST Signature Requirements: Responding With Compassion While Ensuring Informed Consent

The majority of states require the signature of a surrogate decision maker on a POLST form for a patient who lacks decisional capacity. While commendable in its intention to ensure informed consent, in some cases this may lead the surrogate to feel that they are signing their loved one’s “death warrant,” adding to their emotional and spiritual distress. In this paper we argue that such a signature should be recommended rather than required, as it is neither a sufficient nor necessary condition of informed consent. Additional steps—such as requiring the attestation and documentation of the signing health care professional that verbal consent was fully informed and voluntary—can achieve the ultimate goal of respecting patient autonomy without adding to the surrogate’s burden.

Original Research: Understanding Nursing Home Staff Attitudes Toward Death and Dying: A Survey

BACKGROUND

Nearly 70% of nursing home residents are eligible for palliative care, yet few receive formal palliative care outside of hospice. Little is known about nursing home staff attitudes, knowledge, skills, and behaviors related to palliative care.

METHODS

We administered a modified survey measuring attitudes toward death to 146 nursing home staff members, including both clinical and nonclinical staff, from 14 nursing homes.

RESULTS

Nursing home staff generally reported feeling comfortable caring for the dying, but half believed the end of life is a time of great suffering. Pain control (63%), loneliness (52%), and depression (48%) were the most important issues identified with regard to these patients, and there was ambivalence about the use of strong pain medications and the utility of feeding tubes at the end of life. Top priorities identified for improving palliative care included greater family involvement (43%), education and training in pain control (50%) and in management of other symptoms (37%), and use of a palliative care team (35%) at their facility.

CONCLUSIONS

Findings show there is a need for more palliative care training and education, which should be built on current staff knowledge, skills, and attitudes toward palliative care.

Palliative care and infection management at end of life in nursing homes: A descriptive survey

BACKGROUND

Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics.

AIM

The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation.

DESIGN

This is a cross-sectional survey of nationally representative US nursing homes.

SETTING/PARTICIPANTS

Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation.

RESULTS

Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics.

CONCLUSION

The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

Prospective Evaluation of Intensity of Symptoms, Therapeutic Procedures and Treatment in Palliative Care Patients in Nursing Homes

The aim of the study is to evaluate the intensity of symptoms, and any treatment and therapeutic procedures received by advanced chronic patients in nursing homes. A multi-centre prospective study was conducted in six nursing homes for five months. A nurse trainer selected palliative care patients from whom the sample was randomly selected for inclusion. The Edmonton Symptoms Assessment Scale, therapeutic procedures, and treatment were evaluated. Parametric and non-parametric tests were used to evaluate month-to-month differences and differences between those who died and those who did not. A total of 107 residents were evaluated. At the end of the follow-up, 39 had (34.6%) died. All symptoms (p < 0.050) increased in intensity in the last week of life. Symptoms were more intense in those who had died at follow-up (p < 0.05). The use of aerosol sprays (p = 0.008), oxygen therapy (p < 0.001), opioids (p < 0.001), antibiotics (p = 0.004), and bronchodilators (p = 0.003) increased in the last week of life. Peripheral venous catheters (p = 0.022), corticoids (p = 0.007), antiemetics (p < 0.001), and antidepressants (p < 0.05) were used more in the patients who died. In conclusion, the use of therapeutic procedures (such as urinary catheters, peripheral venous catheter placement, and enteral feeding) and drugs (such as antibiotics, anxiolytics, and new antidepressant prescriptions) should be carefully considered in this clinical setting.

Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care

BACKGROUND AND OBJECTIVES

Transitioning to a nursing home (NH) is a major life event for 1.4 million NH residents in the United States. Most post-acute NH admissions plan for rehabilitation and discharge home, but with nearly 70% of NH residents being palliative care (PC) eligible, many evolve into long-term placements secondary to poor health and associated decline in function and/or cognition. This article describes the perceptions of NH PC-eligible residents and families transitioning to life in a NH.

METHODS

Residents at 3 NHs in Northern California (N = 228) were screened for PC eligibility. A convenience sample of PC-eligible residents and their family members (n = 28) participated in qualitative interviews that explored the experience of living as a NH resident with serious illness. Data were analyzed using grounded theory methodology.

RESULTS

Our study provides insights into the experiences of transitioning to a NH from the perspectives of PC-eligible residents and their families. These data describe how PC-eligible residents and their families experienced disempowerment as they perceived being left out of decisions to go to a NH, loss of autonomy once at the NH, dealt with the realization that they would not be going home, and described perceived barriers to going home.

DISCUSSION AND IMPLICATIONS

The inclusive and person-centered model of care that PC provides naturally empowers residents and family members. Adequate provision of PC services, together with changes in policy related to NH culture and benefit management, could improve the experience of transitioning to a nursing home.

Evaluation of a Palliative Care Program for Nursing Homes in 7 Countries: The PACE Cluster-Randomized Clinical Trial

IMPORTANCE

High-quality evidence on how to improve palliative care in nursing homes is lacking.

OBJECTIVE

To investigate the effect of the Palliative Care for Older People (PACE) Steps to Success Program on resident and staff outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized clinical trial (2015-2017) in 78 nursing homes in 7 countries comparing PACE Steps to Success Program (intervention) with usual care (control). Randomization was stratified by country and median number of beds in each country in a 1:1 ratio.

INTERVENTIONS

The PACE Steps to Success Program is a multicomponent intervention to integrate basic nonspecialist palliative care in nursing homes. Using a train-the-trainer approach, an external trainer supports staff in nursing homes to introduce a palliative care approach over the course of 1 year following a 6-steps program. The steps are (1) advance care planning with residents and family, (2) assessment, care planning, and review of needs and problems, (3) coordination of care via monthly multidisciplinary review meetings, (4) delivery of high-quality care focusing on pain and depression, (5) care in the last days of life, and (6) care after death.

MAIN OUTCOMES AND MEASURES

The primary resident outcome was comfort in the last week of life measured after death by staff using the End-of-Life in Dementia Scale Comfort Assessment While Dying (EOLD-CAD; range, 14-42). The primary staff outcome was knowledge of palliative care reported by staff using the Palliative Care Survey (PCS; range, 0-1).

RESULTS

Concerning deceased residents, we collected 551 of 610 questionnaires from staff at baseline and 984 of 1178 postintervention in 37 intervention and 36 control homes. Mean (SD) age at time of death ranged between 85.22 (9.13) and 85.91 (8.57) years, and between 60.6% (160/264) and 70.6% (190/269) of residents were women across the different groups. Residents' comfort in the last week of life did not differ between intervention and control groups (baseline-adjusted mean difference, -0.55; 95% CI, -1.71 to 0.61; P = .35). Concerning staff, we collected 2680 of 3638 questionnaires at baseline and 2437 of 3510 postintervention in 37 intervention and 38 control homes. Mean (SD) age of staff ranged between 42.3 (12.1) and 44.1 (11.7) years, and between 87.2% (1092/1253) and 89% (1224/1375) of staff were women across the different groups. Staff in the intervention group had statistically significantly better knowledge of palliative care than staff in the control group, but the clinical difference was minimal (baseline-adjusted mean difference, 0.04; 95% CI, 0.02-0.05; P < .001). Data analyses began on April 20, 2018.

CONCLUSIONS AND RELEVANCE

Residents' comfort in the last week of life did not improve after introducing the PACE Steps to Success Program. Improvements in staff knowledge of palliative care were clinically not important.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN14741671.

Barriers and facilitators to palliative care education in nursing and residential homes: a rapid review

BACKGROUND

There is insufficient high-quality evidence to suggest that palliative care education can impact care home settings.

AIMS

To identify, appraise and synthesise all available evidence on the barriers and facilitators to providing palliative care education in residential and nursing care homes and to generate recommendations to increase the effectiveness of future palliative care education programmes in care homes.

METHODS

A rapid review searching CINAHL, Medline and ProQuest. One author screened full-text articles for inclusion. Any uncertainties were discussed with a second author.

FINDINGS

Twenty-two articles were included in the full review. Analysis of the included articles revealed the following overlapping themes: structural systems; cultural and personal issues; and knowledge translation issues with interaction.

CONCLUSION

Addressing the barriers and facilitators when designing palliative care education programmes for care homes will lead to more successful outcomes.

Pain and Emergency Department Use in the Last Month of Life Among Older Adults With Dementia

CONTEXT

Pain may be a potentially modifiable risk factor for expensive and burdensome emergency department (ED) visits near the end of life for older adults with dementia.

OBJECTIVES

The objective of this study was to assess the effect of pain and unmet need for pain management on ED visits in the last month of life in older adults with dementia.

METHODS

This is a mortality follow-back study of older adults with dementia in the National Health and Aging Trends Study who died between 2012 and 2014, linked to Medicare claims.

RESULTS

Two hundred eighty-one National Health and Aging Trends Study decedents with dementia met criteria (mean age 86 years, 61% female, 81% white). Fifty-seven percent had at least one ED visit in the last month of life, and 46.5% had an ED visit that resulted in a hospital admission. Almost three out of four (73%) of decedents experienced pain in the last month of life, and 10% had an unmet need for pain management. After adjustment for age, gender, race, educational attainment, income, comorbidities, and impairment in activities of daily living, pain was not associated with increased ED use in the last month of life (adjusted incident rate ratio 0.87, 95% CI 0.64-1.17). However, decedents with unmet need for pain management had an almost 50% higher rate of ED visits in the last month of life than those without unmet needs (adjusted incident rate ratio 1.46, 95% CI 1.07-1.99).

CONCLUSION

Among older adults with dementia, unmet need for pain management was associated with more frequent ED visits in the last month of life.