Differing perceptions of end-of-life care in long-term care

The impact of existential vulnerability for nursing home doctors in end-of-life care: A focus group study

OBJECTIVE

Explore the impact of existential vulnerability for nursing home doctors' experiences with dying patients and their families.

METHODS

We conducted a qualitative study based on three focus group interviews with purposive samples of 17 nursing home doctors. The interviews were audio-recorded, transcribed, and analyzed with systematic text condensation.

RESULTS

Nursing home doctors experienced having to balance treatment compromises in order to assist patients' and families' preparation for death, with their sense of professional conduct. This was an arduous process demanding patience and consideration. Existential vulnerability also manifested as powerlessness mastering issues of life and death and families' expectations. Standard phrases could help convey complex messages of uncertainty and graveness. Personal commitment was balanced with protective disengagement on the patient's deathbed, triggering both feelings of wonder and guilt.

CONCLUSION

Existential vulnerability is experienced as a burden of powerlessness and guilt in difficult treatment compromises and in the need for protective disengagement, but also as a resource in communication and professional coping.

PRACTICE IMPLICATIONS

End-of-life care training for nursing home doctors should include self-reflective practice, in particular addressing treatment compromises and professional conduct in the dialogue with patient and next-of-kin.

Integration of Palliative Care Services in the Intensive Care Unit: A Roadmap for Overcoming Barriers

Clinicians working in the intensive care unit (ICU) confront death and dying daily. ICU care can be inconsistent with a patient's values, preferences, and previously expressed goals of care. Current evidence promotes the integration of palliative care services within the ICU setting. Palliative care bridges the gap between comfort and cure, and these services are growing in the United States. This article discusses the benefits and barriers to integration of ICU and palliative care services, and a stepwise approach to implementation of palliative care services. Integration of palliative care services into ICU workflow is increasingly seen as essential to providing high-quality, comprehensive critical care.

Patient safety in the nursing home: how nursing staff assess and communicate about change in condition

Nursing homes must improve quality of care even as it becomes increasingly complex, and patient safety science may provide a helpful paradigm. Training materials are needed to build staff capacity for clinical assessment and communication, thereby improving care processes. Designed to develop curricular materials, this study used focus groups to determine how experienced nurses and aides assess and communicate about resident clinical changes. Four focus groups were conducted, and interviews were analyzed for themes in an iterative process by multidisciplinary team members. Staff reported that consistent caregiving enables detection of subtle clinical changes; aides further noted the importance of affective bonding. Aides and nurses alike regarded all clinical changes as potentially significant, while nursing staff lacked a consistent approach to assessment. Using a patient safety framework, structural changes and process elements were identified as important topics for further training to support clinical communication and improve resident and facility outcomes.

The Intersection of Long-Term Care and End-of-Life Care

High-quality end-of-life care is an important component of high-quality long-term care, yet many elderly individuals receiving long-term care services do not obtain good care as they approach death. This study provides a systematic review of articles that describe care received at the nexus of long-term care and end-of-life care. The articles identified three primary types of barriers to high-quality end-of-life care in long-term care settings: delivery system barriers intrinsic to long-term care settings, barriers related to features of coverage and reimbursement, and barriers resulting from the current regulatory approach for long-term care providers. The authors recommend areas for future research that would help to support progress on public policy that governs the provision of care at this important intersection.

Review: the quality of dying and death: a systematic review of measures

To determine whether modern medicine is facilitating 'good' deaths, appropriate measures of the quality of dying and death must be developed and utilized. The purpose of this paper is to identify quality of dying and death measurement tools and to determine their quality. MEDLINE (1950-2008), Healthstar (1966-2008), and CINAHL (1982-2008) were searched using keyword terms 'quality of dying/death' and 'good/bad death'. Papers that described a quality of dying and death measure or that aimed to measure the quality of dying and death were selected for review. The evaluation criteria included a description of the measure development (validated or ad hoc), the provision of a definition of quality of dying and death, an empirical basis for the measure, the incorporation of multiple domains and the subjective nature of the quality of dying and death construct, and responsiveness to change. Eighteen measures met the selection criteria. Six were published with some description of the development process and 12 were developed ad hoc. Less than half were based on an explicit definition of quality of dying and death and even fewer relied on a conceptual model that incorporated multidimensionality and subjective determination. The specified duration of the dying and death phase ranged from the last months to hours of life. Of the six published measures reviewed, the Quality of Dying and Death questionnaire (QODD) is the most widely studied and best validated. Strategies to measure the quality of dying and death are becoming increasingly rigorous. Further research is required to understand the factors influencing the ratings of the quality of dying and death.

Multi-faceted palliative care intervention: aged care nurses' and care assistants' perceptions and experiences

AIM

This paper is a report of a study to describe residential aged care nurses' and care assistants' perceptions of a multi-faceted palliative care intervention to identify potential areas to be addressed during subsequent action research phases.

BACKGROUND

Action research was used to enhance the delivery of a palliative approach in residential aged care. The chronic care model guided the development of a multi-faceted intervention. This involved the: (1) establishment of a 'link nurse' role; (2) learning and development strategies for nurses, care assistants and general practitioners; (3) use of multi-disciplinary team meetings; and (4) access to specialist consultation.

METHOD

A purposive sample (n = 28) of aged care nurses and care assistants participated in a series of four focus groups conducted in July 2005. Thematic content analysis of the transcripts was performed.

FINDINGS

Four themes emerged: (1) targeted education can make a difference; (2) a team approach is valued; (3) clinical assessment tools are helpful; and (4) using the right language is essential. Participants described increased understanding of palliative care concepts, enhanced competencies, greater confidence to deliver palliative care and a desire to adopt a multi-disciplinary approach to care planning.

CONCLUSION

Sustaining a culture that is committed to ongoing learning and development interventions and creating multi-disciplinary teams in the aged care setting is critical to embedding a palliative approach. The chronic care model is a useful framework to guide the development of interventions leading to better palliative care outcomes for residents and their families.

Medical Decision-Making in the Nursing Home: A Comparison of Physician and Nurse Perspectives

The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family's and resident's wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians' reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.

Nursing Home Capabilities and Decisions to Hospitalize: A Survey of Medical Directors and Directors of Nursing

OBJECTIVES

To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents.

DESIGN

Cross-sectional survey.

SETTING

Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states.

PARTICIPANTS

Medical directors and directors of nursing (DONs).

MEASUREMENTS

Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice.

RESULTS

The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive.

CONCLUSION

Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.

End-of-life care in U.S. nursing homes: a review of the evidence

OBJECTIVES

The purpose of this study was to systematically review the empiric evidence on end-of-life care in nursing homes in the United States The guiding research question for this review was what is the state of research evidence in end-of-life care in long-term care?

DESIGN

We conducted a systematic review of the literature.

DATA

The review was limited to published and indexed research in peer-reviewed journals in five major databases between 1995 and October 2002.

RESULTS

The initial search yielded a total of 395 articles. The search was narrowed, focusing on nursing homes in the United States and empiric research. The result was 43 articles related to research in end-of-life care in American nursing homes. It was categorized into eight foci: prognosis, pain, hospice, hospitalization, advanced care planning, communication, family perceptions, and miscellaneous.

CONCLUSION

There is a dearth of research published in end-of-life care in the nursing home setting. What is available is primarily descriptive. The empiric research only documents poor end-of-life care in U.S. nursing homes. Empiric evidence has grown in this area, but there is now a need for research of creative and innovative solutions aimed at improving the quality of end-of-life care in this setting.

"Getting Everyone on the Same Page": Nursing Home Physicians' Perspectives on End-of-Life Care

PURPOSE

To improve understanding of nursing home physicians' perspectives regarding end-of-life care, and to suggest directions for further research.

METHODS

An exploratory qualitative design based on interviews of 12 nursing home physicians, 10 of whom were medical directors. Medical students served as interviewers.

SAMPLE

A purposeful sampling strategy yielded interviews with 12 physicians. The sample was selected based on "intensity sampling," which seeks information-rich but not extreme cases. Ten of the 12 physicians were nursing home medical directors; all respondents practiced at least 4 years part-time or full-time in a nursing home setting. Respondents varied by age, gender, urban/rural location, and fellowship training (half the sample had completed a geriatrics fellowship). Seven physicians were affiliated with an academic medical center.

RESULTS

Four themes were identified in the analysis of the 12 interview transcripts: extensive familiarity with dying; consensus is integral to good end-of-life care; obstacles can interfere with consensus; and advance directives set the stage for conversations about end-of-life care. The importance of consensus, both in terms of prognosis and in developing a palliative care plan, emerged as the major finding.

CONCLUSIONS

For the 12 physicians in this study consensus about the resident's status and an appropriate care plan are important features of good end-of-life care. Further research is needed to determine if other members of the health care team (i.e., residents, family members, nursing staff, social worker, etc.) also value consensus highly. It will be important to determine what barriers to consensus other team members identify. Based on the understanding generated from this study, a refinement of the general Education for Physicians on End-of-Life Care (EPEC) model describing the relationship between curative and palliative care is proposed for nursing homes. The refinement underscores the points at which the team might consider revisiting consensus about the resident's status and care plan.

Needs of the dying in nursing homes

OBJECTIVE

To describe the palliative care needs of dying nursing home residents during the last 3 months of life.

METHODS

Nurses, aides, and family members completed structured interviews after all deaths of residents in two nursing homes during a 1-year study period. For each resident who died, family and staff caregivers answered parallel questions on the presence of physical and emotional symptoms, unmet needs for treatment of these symptoms, and the quality of the dying experience.

RESULTS

Of 259 eligible respondents 176 completed interviews (68%). Decedents' average age was 82, and 90% died in the nursing home rather than in a hospital. Most deaths were preceded by orders to withhold resuscitation (79%) and other treatments (39%). The most common physical symptoms were pain (86%), problems with personal cleanliness (81%), dyspnea (75%), incontinence (59%), and fatigue (52%). Depressed mood (44%), anxiety (31%), and loneliness (21%) were common emotional symptoms. Respondents believed residents needed more treatment than they received for emotional symptoms (30%), personal cleanliness (23%) and pain (19%). Fifty-eight percent of respondents believed the resident experienced a "good death," as they would have wanted it to be.

CONCLUSIONS

Dying nursing home residents need improved emotional and spiritual care, help with personal cleanliness, and treatment for pain. Efforts to improve end-of-life care in nursing homes should combine traditional palliative care services with increased attention to emotional symptoms and personal care services.