End-of-Life Nutrition Considerations: Attitudes, Beliefs, and Outcomes

Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life

BACKGROUND

Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context.

METHODS

Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order.

RESULTS

Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint.

CONCLUSIONS

Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options.

IMPLICATIONS FOR PRACTICE

Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.

Resources to Support Decision-Making Regarding End-of-Life Nutrition Care in Long-Term Care: A Scoping Review

Resources are needed to aid healthcare providers and families in making end-of-life nutrition care decisions for residents living in long-term care settings. This scoping review aimed to explore what is reported in the literature about resources to support decision-making at the end of life in long-term care. Four databases were searched for research published from 2003 to June 2023. Articles included peer-reviewed human studies published in the English language that reported resources to support decision-making about end-of-life nutrition in long-term care settings. In total, 15 articles were included. Thematic analysis of the articles generated five themes: conversations about care, evidence-based decision-making, a need for multidisciplinary perspectives, honouring residents' goals of care, and cultural considerations for adapting resources. Multidisciplinary care teams supporting residents and their families during the end of life can benefit from resources to support discussion and facilitate decision-making.

Perceptions and Knowledge Regarding Medical Situations at the End of Life among Older Adults in Switzerland

Background: Perceptions and knowledge regarding end-of-life health and health care can influence individuals' advance care planning, such as the completion and content of advance directives. Objectives: To assess older adults' perceptions of medical end-of-life situations in Switzerland along with their accuracy and corresponding associations with sociodemographic characteristics. Design: This is an observational study. Setting/study subjects: A nationally representative sample of adults aged 58 years and older who participated in wave 8 (2019/2020) of the Swiss part of the Survey of Health, Ageing, and Retirement in Europe (cooperation rate: 94.3%). Measurements: Subjective likelihood of 11 end-of-life situations on a 4-point scale: very unlikely (0-25%), rather unlikely (26%-50%), rather likely (51%-75%), and very likely (76%-100%). Results: Older adults' perceptions of end-of-life medical situations in Switzerland were rather heterogeneous and often inaccurate. Study subjects overestimated the success of cardiopulmonary resuscitation, the utility of a fourth-line chemotherapy, of hospital admission for pneumonia for patients with advanced dementia, and for artificial nutrition and hydration in the dying phase, while underestimating the effectiveness of pain management in this situation. Less than 28% of older adults correctly assessed the likelihood of dying in a nursing home, hospital, or at home, respectively. Inaccurate views were more frequent in men (p < 0.01) and individuals with financial difficulties (p < 0.05), whereas adults aged 75+ years (p < 0.01) and respondents from the German-speaking part of Switzerland (p < 0.01) had more accurate perceptions. Conclusions: The wide variation and low accuracy of end-of-life perceptions suggest considerable scope for communication interventions about the reality of end-of-life health and health care in Switzerland.

Reasons for and against Nutritional Interventions. An Exploration in the Nursing Home Setting

Malnutrition (MN) is widespread in nursing homes. Sometimes, but not always, nutritional interventions (NIs) are made, and the reasons for or against NIs are unknown. The aim of this cross-sectional study was to describe these reasons for residents with and without MN according to nurses’ subjective judgement and according to objective signs of MN. The nutritional status of 246 nursing home residents was subjectively judged by nurses (MN, at risk of MN, no MN) and objectively assessed by body mass index (BMI), weight loss (WL), and low food intake. NIs (enriched meals and/or oral nutritional supplements) were recorded using a standardized questionnaire, and nurses’ main reasons for (not) giving NIs were obtained in an open question. Of the residents, 11.0% were subjectively malnourished, and 25.6% were at risk of MN; 32.9% were malnourished according to objective criteria. Overall, 29.7% of the residents received NIs, 70.4% of those with MN as assessed by the nurses, 53.0% of those with objective MN, and 11.0% and 18.0% of non-malnourished residents, respectively. Reasons for NIs most often stated were low intake (47.9%), WL (23.3%), and low BMI (13.7%). Reasons against NIs mostly mentioned were adequate BMI (32.9%) and sufficient intake (24.3%). The lack of NIs for residents with MN was partially—but not always—explained by valid reasons. As residents without MN frequently received NIs, criteria for both MN rating and providing NIs, require closer scrutiny.