Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study

We need a radical change to take place now´-The potential of integrated healthcare for rural long-term care facilities

OBJECTIVES

This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences.

METHODS

Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape.

RESULTS

Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities.

CONCLUSIONS

Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings.

Advance care planning with older Norwegian adults in their homes: a narrative ethnographic study

BACKGROUND

The aim of advance care planning (ACP) is to enable patients to define and discuss their values and preferences to ensure that the care they receive is consistent with their needs and wishes. Most studies of ACP with older adults focus on conversations conducted in institutions. This study aimed to explore how ACP with older patients is carried out and experienced by healthcare professionals when the conversations occur in their private homes.

METHODS

The data were obtained from participant observations of ACP conversations in the homes of eight older patients with advanced cancer, which also involved relatives and healthcare professionals. Additionally, ethnographic interviews were conducted with the healthcare professionals. We undertook a narrative analysis of what was said, and how the individuals acted and interacted.

RESULTS

The home influenced both the substance and form of the ACP conversations. The patients and relatives welcomed the healthcare professionals as guests and were encouraged to share their perceptions of their current situation, joys and worries. Their values were often implicit in their stories about past experiences. The planning mainly focused on life-prolonging treatment and the preferred future place of care. Several patients were not ready to discuss one or more ACP issues. The palliative-care-team physician addressed the patients' readiness for ACP by asking for permission to move on to a different topic, shifting between serious and lighter topics, and using elements from the home as 'door openers' to continue conversations. ACP conversations were an essential basis for future palliative care and cooperation, giving important additional information about the patient and their relatives.

CONCLUSION

Conducting the ACP conversations in the patients' homes ensured a homely atmosphere that facilitated a caring approach when sensitive issues were discussed, and in turn supported the identification of important personal values. The healthcare professionals expressed that the ACP conversations represented an essential common reference point and provided a shared awareness of the expected disease trajectory and the values, preferences and needs of the patient. These findings are particularly important given that many older patients struggle to verbalize or form an opinion on issues affecting their future.

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

BACKGROUND

Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions.

METHODS

This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis.

DISCUSSION

The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Supporting autonomy for people with dementia living in nursing homes: A rapid realist review

BACKGROUND

For people with dementia living in nursing homes, autonomy is important. However, they experience difficulty with being heard as an autonomous person, as well as with expressing their preferences and choices. The question is how to support their autonomy.

OBJECTIVE

Despite extensive efforts to support autonomy in daily care for people with dementia living in nursing homes, we do not know exactly what works for whom, in which context, how and why. The objective of this realist review is to explore what is known in literature on autonomy support interventions for people with dementia in nursing homes.

DESIGN

A rapid realist review of literature.

REVIEW METHODS

To understand how autonomy is supported, a realist approach was applied that entailed identifying the research question, searching for information, performing a quality appraisal, extracting data, synthesizing the evidence and validating the findings with a panel of experts. Causal assumptions were derived from articles found in four bibliographic databases (PubMed, PsychInfo, Cochrane and CINAHL) leading to context (C)-mechanism (M)-outcome (O) configurations.

RESULTS

Data extraction from the included articles ultimately resulted in sixteen CMO configurations on four themes: a. preferences and choice: interventions for supporting autonomy in nursing homes and their results, b. personal characteristics of residents and family: people with dementia and their family being individuals who have their own character, habits and behaviors, c. competent nursing staff each having their own level of knowledge, competence and need for support, and d. interaction and relationships in care situations: the persons involved are interrelated, continuously interacting in different triangles composed of residents, family members and nursing staff.

CONCLUSION

The findings showed that results from interventions on autonomy in daily-care situations are likely to be just as related not only with the characteristics and competences of the people involved, but also to how they interact. Autonomy support interventions appear to be successful when the right context factors are considered.

Advance Care Planning Among Elderly Acquired Immunodeficiency Syndrome Patients: A Qualitative Preference Study

Complications arising from human immunodeficiency virus may affect the ability of elderly AIDS patients to communicate and make decisions about future medical care. It is important for elderly AIDS patients to be able to express effectively their preferences for future treatments and care. This study explored preferences and influencing factors of advance care planning among elderly AIDS patients. A semistructured interview outline was developed based on the theory of planned behavior. A qualitative preference interview was conducted among 16 eligible elderly AIDS patients. Using thematic analysis, the data were analyzed and categorized into 3 themes and 9 subthemes that were classified under the theory of planned behavior framework. The 3 themes were as follows: a positive attitude toward advance care planning, a strong desire for family and social support, and some obstacles to discussing advance care planning in the current environment. These themes provided valuable insights to advance care planning educators and practitioners from different work environments and units to aid them in constructing future ACP intervention models for elderly AIDS patients.

Positive attitudes to advance care planning - a Norwegian general population survey

Background

Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning.

Methods

An electronic survey to a nationally representative web panel of Norwegian adults.

Results

From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness.

Conclusions

Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.

Exploring Differential Perceptions and Barriers to Advance Care Planning in Dementia among Asian Patient-Caregiver Dyads-A Mixed-Methods Study

A parallel mixed-methods study on 20 patient–caregiver dyads in an Asian population was conducted to explore the differential perceptions and barriers to ACP in dementia. We recruited English-speaking patients with mild dementia and their caregivers. A trained ACP facilitator conducted ACP counseling. Patient–caregiver dyads completed pre–post surveys and participated in post-counseling qualitative interviews. We used mixed-methods analysis to corroborate the quantitative and qualitative data. Differential perceptions of ACP were reported among dyads, with caregivers less inclined for further ACP discussions. Post-ACP counseling, caregivers were significantly more likely to acknowledge barriers to ACP discussions than patients (57.9% versus 10.5%, p = 0.005). Thematic analysis of the interview transcripts revealed four themes around barriers to ACP: patient-related factors (transference of decision making, poor cognition and lack of understanding, and dis-inclination to plan for the future), caregiver-related factors (perceived negative impact on the patient, caregiver discomfort, and confidence in congruent decision making), socio-cultural factors (taboos, superstitions, and religious beliefs), and the inappropriate timing of discussions. In a collectivist Asian culture, socio-cultural factors pose important barriers, and a family-centric approach to initiation of ACP may be the first step towards engagement in the ACP process. For ACP in dementia to be effective for patients and caregivers, these discussions should be culturally tailored and address patient, caregiver, socio-cultural, and timing barriers.