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

Proactive end-of-life conversations in residential care homes: a qualitative interview study exploring residents' and family members' experiences

BACKGROUND

Due to population aging, residential care homes are increasingly providing end-of-life care for residents with multiple chronic illnesses and cognitive decline. Proactive end-of-life communication, a component of Advance Care Planning, has been suggested as a means of providing high-quality care aligned with residents' preferences and supporting involved family members. Despite growing knowledge about the benefits of early communication concerning end-of-life care preferences, such conversations are still rare in the context of residential care homes, and little is known about how they are perceived by residents and family members. The aim of this study is to explore the outcomes experienced by residents and family members who have participated in proactive end-of-life conversations in residential care homes.

METHODS

This qualitative study is embedded within a participatory action research project implementing proactive end-of-life conversations in five Swedish residential care homes, using a conversation tool. In this study we performed 18 interviews with eleven residents and eight family members after they had participated in staff initiated proactive end-of-life conversations. Data were analyzed using interpretive description.

RESULTS

Residents and family members experienced several outcomes of proactive end-of-life conversations presented in three closely interconnected themes: (1) Enabling open communication, (2) Creating space for knowledge exchange, and (3) Contributing to feelings of confidence and relationship building.

CONCLUSIONS

Proactive end-of-life conversations generated several beneficial outcomes for residents and family members, including those with cognitive decline. The study demonstrated that the conversations may strengthen person-centered care and family support in this context. Based on these findings, proactive end-of-life conversations have the potential for use by residential care home staff.

Improving relationship-centered care through evaluation meetings with the resident-family-caregiver triad in nursing homes: a qualitative study

BACKGROUND

Providing and improving relationship-centered care has gained increased importance in long-term care. However, quality improvement strategies are predominantly based on quantitative quality measures for care professionals. Therefore, the aim of this study was to explore how narrative data collected with Connecting Conversations is used in evaluation meetings to improve RCC.

METHODS

A qualitative approach using structured observations was used. The participants were care professionals, residents and family members from two nursing home wards. The participating wards organized evaluation meetings to discuss the experienced quality of care based on narrative data collected with Connecting Conversations. To analyze the process of improving RCC, the organization of these meetings and the content were observed by independent researchers, and detailed notes were taken. The data were analyzed thematically by using conventional content analysis.

RESULTS

In total, three evaluation meetings were organized. Primarily, care professionals were invited to discuss the results of the interviews. One ward organized a meeting for care professionals, residents and family members, and the other decided not to invite them. The discussion of themes related to experienced quality of care within the evaluation meetings was less profound than during the interviews. In total, 12 overarching themes concerning experienced quality of care were discussed in the Connecting Conversations' interviews. Nine themes were also mentioned in one or more evaluation meetings (i.e., activities for residents, personalized attention and preferences of residents, feeling at home and communication within the care triad).

CONCLUSION

When using narrative data on quality of care to improve relationship-centered care, the full potential of narrative data is underutilized as discussions focussed on incidental problem solving rather than deeper reflections on the meaning of events in providing relationship-centered care. Establishing trust within the care triad of care professionals, family members, and residents is essential to improve relationship-centered care collaboratively.

How is autonomy supported for people with dementia living in a nursing home, to what extent and under what circumstances? A realist evaluation

BACKGROUND

Being autonomous is important for people with dementia living in nursing homes. Our recent realist review indicated that supporting their autonomy depends on various aspects.

OBJECTIVE

This study aimed to uncover how people with dementia, their family members and care and treatment professionals experience the support of autonomy in daily care practice: what works, to what extent and under what circumstances.

DESIGN

A realist evaluation was performed using qualitative methods.

METHODS

We applied a realist approach through interviews with family members and care and treatment professionals, as well as on-site observations: due to their cognitive condition we could not exchange mutual views with residents directly. We performed these interviews and observations on site to find out how, to what extent and under what circumstances, supporting autonomy interventions work in daily practice situations. Causal assumptions were derived from the empirical data, leading to Context (C) -Mechanism (M) - Outcome (O) configurations.

RESULTS

Data extraction from 24 interviews and 8 observations resulted in 19 CMO configurations on four themes: A. Autonomy and boundaries: providing maximum autonomy influenced by safety and health restrictions. B. Organization of daily care processes: the influence of attempting to increase efficiency by working routines. C. Team competences and collaboration: the possibilities of care professionals to acquire the relevant competences and an appropriate level of team collaboration. D. Interaction and relationships: the accomplishment of a working relationship between residents, their family and care and treatment professionals.

CONCLUSION

The results showed that supporting autonomy was valued highly by all stakeholders. In streamlining care processes, working routines were influential to supporting autonomy. Weighing risky choices for people with dementia in their decision making was another factor. Our study indicated that realizing autonomy is facilitated by a capable and collaborative team of professionals and by a working relationship between persons living with dementia, family members and professionals.

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.

Mechanisms and contextual influences on the implementation of advance care planning for older people in long-term care facilities: A realist review

BACKGROUND

Older people in long-term care facilities face clinical uncertainty and unpredictable decline. Advance care planning enables older people to identify preferences and wishes for future treatment and care before any loss of capacity. However, it is unclear how, why and under what circumstances the implementation of advance care planning for older people can be normalised into routine practice within long-term care facilities.

OBJECTIVE

To identify and explain mechanisms and contextual factors that underpin the implementation of advance care planning for older people in long-term care facilities.

DESIGN

Realist review.

SETTING(S)

Long-term care facilities.

METHODS

Consistent with realist review methodology, we developed the initial programme theory by scoping reviews, engaging UK and China stakeholders and utilising the Normalisation Process Theory. MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus were subsequently searched from 01/01/1990 to 11/06/2021. Inductive and deductive coding was used to generate context-mechanism-outcome configurations, which were iteratively tested to refine the programme theory.

RESULTS

5459 records were identified, and 48 were retained for final synthesis. Seven context-mechanism-outcome configurations were identified: (1) carry out sensitive conversation gradually in a nonthreatening way; (2) identify 'a window of opportunity'; (3) deliver sustainable and available training; (4) build a collaborative and multidisciplinary network; (5) conduct collaborative negotiation to achieve shared decision-making; (6) secure active leadership buy-in; (7) keep conversation and documentation on track. A logic model was developed to conceptualise the causal pathways between the contexts, mechanisms, and outcomes.

CONCLUSIONS

Normalising conversations about death is paramount to mainstreaming advance care planning implementation in long-term care facilities. The key to achieving this is older people, family members and staff have a shared understanding of the aims, values, and potential benefits of advance care planning. Advance care planning should be introduced at a time that is important to older people and families, rather than being process-driven. Nurse facilitators play a vital role in ensuring older people's voices are heard and in building bridges between participants in advance care planning. The findings of this study inform the appropriate development and evaluation of advance care planning interventions for older people in long-term care facilities. Further research is needed to explore mechanisms that underpin the implementation of advance care planning in Asian countries.

REGISTRATION

This review is registered with the International Prospective Register of Systematic Reviews (CRD42021214317).

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.