Staff Perspectives of Barriers to Access and Delivery of Palliative Care for Persons With Dementia in Long-Term Care

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.

Palliative Care in Early Dementia

BACKGROUND

Palliative care is recommended for all people with dementia from diagnosis through end-of-life. However, palliative care needs and effective elements of palliative care are not well-defined for the earlier stages of dementia.

OBJECTIVE

To systematically map current research on palliative care early in the disease trajectory of dementia.

DESIGN

Scoping review of scientific literature.

DATA SOURCES

PubMed, CINAHL, EMBASE, Cochrane, PsycINFO, Web of Science.

REVIEW METHODS

We included studies published in English over the last decade (through March 2022) that focused on palliative care in early stages of dementia and targeted outcomes in palliative care domains. Two authors independently screened abstracts and full texts and scored the quality of included studies using tools by the Joanna Briggs Institute.

RESULTS

Among the 77 papers reviewed, few addressed early stages of dementia specifically. We found that: 1) While "early" palliative care was not well-defined in the literature, evidence indicated that palliative care needs were present at or before diagnosis and across the trajectory. Notable opportunities for palliative care arise at 'tipping points' (i.e., when symptoms, functional status, or caregiving needs change). 2) Palliative care needs in early dementia include advocacy for goal-aligned care in the future, reassurance against the threat of negligence and abandonment by caregivers, planning for future scenarios of care (practical, individual, and relational needs), and establishing of long-term relationships with providers entrusted for care later in disease. 3) Elements of effective palliative care in early dementia could include dementia-specific ACP and goals of care discussions, navigation for building a network of support, provision of tools and resources for family, tailored care and knowledge of the person, and well-prepared dementia-care providers. The scarcity of palliative care studies aimed at early disease indicates a gap in the evidence in dementia care.

CONCLUSION

The literature on palliative care in early dementia is sparse. Future studies should focus on assessment tools for optimizing timing of palliative care in early dementia, gaining better understanding of patient and family needs during early phases of disease, and providing training for providers and families in long-term relationships and communication around goals of care and future planning.

Nutrition and Non-Nutrition-Related Challenges Predict Time to Death in Long-Term Care Residents: A Retrospective Chart Review

Purpose

Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death.

Patients and Methods

A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal.

Results

Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death.

Conclusion

This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.

How Do We Talk With People Living With Dementia About Future Care: A Scoping Review

A diagnosis of dementia often comes with difficulties in understanding a conversational context and expressing how one feels. So far, research on how to facilitate advance care planning (ACP) for people with dementia focused on defining relevant themes and topics for conversations, or on how to formalize decisions made by surrogate decision makers, e.g., family members. The aim of this review is to provide a better scope of the existing research on practical communication aspects related to dementia in ACP conversations. In November 2020, seven databases were searched to select papers for inclusion (Proquest, Medline, Embase, Scopus, Psycinfo, Amed, and Cinahl). This search was updated in December 2021. The search strategy consisted of three tiers (related terms to "dementia," "communication" and "ACP"), intersected by using the Boolean term "AND," and resulted in 787 studies. Two researchers followed explicit criteria for two sequential levels of screening, based on titles and abstracts and full papers. A total of 22 studies were included for data analysis. Seven topics (i.e., importance of having ACP conversations, knowledge gap, inclusion of people with dementia in ACP conversations, policy vs. practice, adapting to cognitive changes, adapting to psychosocial changes, and adapting to emotional changes) emerged clustered around two themes (i.e., communicating with people with dementia in ACP, and changes in communication due to dementia). This scoping review provides practical suggestions for healthcare professionals to improve ACP communication and uncovered gaps in research on communication aspects related to dementia in ACP conversations, such as non-verbal behavior, timing and implementation, and personal preferences.

Prognostic decision-making about imminent death within multidisciplinary teams: a scoping review

OBJECTIVE

To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients.

DESIGN

Scoping review.

SETTING

Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings.

DATA SOURCES

The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients.

RESULTS

40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers.

CONCLUSIONS

Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.

Care dependency of patients and residents at the end of life: A secondary data analysis of data from a cross-sectional study in hospitals and geriatric institutions

AIMS AND OBJECTIVES

The holistic care dependency concept can be applied to gain comprehensive insights into individuals' care needs in the end-of-life (EoL) phase. This study was carried out to measure and characterise the "care dependency" phenomenon in this phase and to obtain deeper knowledge about this phenomenon.

BACKGROUND

The end of a human life is often characterised by a physical decline, often implying that a high amount of care is needed. Non-malignant diseases can develop unpredictably; therefore, it is difficult to detect the onset of the EoL phase.

DESIGN

Data were collected in a cross-sectional multicentre study, using the Austrian Nursing Quality Measurement 2.0.

METHODS

Descriptive and multivariate statistical methods were used. Care dependency was measured with the Care Dependency Scale (CDS). The study follows the STROBE guideline.

RESULTS

Ten per cent (n = 389) of the sample (N = 3589) were allocated to "a pathway for management of patients at the end of life." The patients and residents in the EoL phase are significantly older and more often diagnosed with dementia, and circulatory system and musculoskeletal system diseases. Of these patients, 60% were care dependent completely or to a great extent. Dementia and age represent main influencing factors that affect the degree of care dependency at the end of life.

CONCLUSION

Our results show that the "typical" EoL patient or resident is female, old and affected by dementia and/or circulatory system diseases. Dementia and age were identified as main factors that contribute to very high care dependency.

RELEVANCE TO CLINICAL PRACTICE

The measurement of care dependency may support the identification of special care needs in the EoL phase. Gaining deeper knowledge about the care dependency phenomenon can also help healthcare staff better understand the needs of patients with non-malignant conditions in their last phase of life.

Palliative Care and Dementia: What All Advanced Practice Nurses Should Know

Dementia is a progressive, incurable condition that causes limitations in life and should be recognized as a life-limiting condition. Health care professionals should understand its trajectory to better manage symptoms and to provide early and ongoing advance care planning. Advanced practice registered nurses are uniquely qualified to work with patients and their families to identify care preferences and then to align treatments to them. Palliative care and hospice are important interventions that should be integrated into the management of patients with dementia. Additionally, early integration of palliative medicine can better manage symptoms and lessen the strain on loved ones.

Caring for Patients With Dementia at End of Life

Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.

"A good death but there was all this tension around"- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

BACKGROUND

End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia.

METHODS

Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis.

RESULTS

20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding.

CONCLUSION

Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident's terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

Referral criteria to specialist palliative care for patients with dementia: A systematic review

BACKGROUND

Patients with dementia often have significant symptom burden and a progressive course of functional deterioration. Specialist palliative care referral may be helpful, but it is unclear who and when patients should be referred. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with dementia.

METHODS

We searched Ovid MEDLINE, Ovid Embase, Ovid PsycInfo, Cochrane Library, PubMed, and CINAHL databases for articles from inception to December 3, 2019, related to specialist palliative care referral for dementia. Two investigators independently reviewed the citations for inclusion, extracted the referral criteria, and categorized them thematically.

RESULTS

Of the 1788 citations, 59 articles were included in the final sample. We identified 13 categories of referral criteria, including 6 disease-based and 7 needs-based criteria. The most commonly discussed criterion was "dementia stage" (n = 43, 73%), followed by "new diagnosis of dementia" (n = 17, 29%), "medical complications of dementia" (n = 12, 20%), "prognosis" (n = 11, 19%), and "physical symptoms" (n = 11, 19%). Under dementia stage, 37/44 (84%) articles recommended a palliative care referral for advanced dementia. Pneumonia (n = 6, 10%), fall/fracture (n = 4, 7%), and decubitus ulcers (n = 4, 7%) were most commonly discussed complications to trigger a referral. Under prognosis, the time frame for referral varied from <2 years of life expectancy to <6 months. 3 (5%) of articles recommended "surprise question" as a potential trigger.

CONCLUSIONS

This systematic review highlighted the lack of consensus regarding referral criteria for palliative care in patients with dementia and the need to identify timely triggers to standardize referral.

Enhancing Care for Long-Term Care Residents Approaching End-of-Life: A Mixed-Methods Study Assessing a Palliative Care Transfer Form

BACKGROUND

Many barriers exist in providing quality end-of-life care in long-term care (LTC), including transitions of care between acute care and LTC. Transfer forms can be beneficial in ensuring resident's end-of-life care needs are coordinated between different settings. The NYGH-LTC Transfer Form is a newly developed tool created to enhance care for residents transferred from acute care back to their LTC home for end-of-life.

STUDY AIM

Assess the perceived ease of use, usefulness, and care-enhancing potential of the NYGH-LTC Transfer Form by interprofessional LTC staff.

METHODS

The study population included interprofessional staff members at 2 LTC homes in Toronto, Canada. Quantitative data was obtained through surveys and qualitative data was obtained through focus groups.

RESULTS

There were a total of 34 participants. 79.4% of participants agreed the form was easy to use and 82.4% agreed it would improve care. Subgroup analysis demonstrated that participants with greater than 20 years experience were less likely to agree that it would improve care (p = 0.01). Qualitative analysis generated 4 themes: 1) Strengths, 2) Areas of Improvement, 3) Information Sharing, and 4) Communication.

CONCLUSIONS

The NYGH-LTC Transfer Form was overall well-evaluated. The form was seen as most useful for those with less experience or less confidence in palliative care. Communication was identified as a major barrier to successful transitions of care and increased bidirectional verbal communication is needed in addition to the form.

The Attitudes of Physicians and the General Public toward Prognostic Disclosure of Different Serious Illnesses: a Korean Nationwide Study

BACKGROUND

Although international guidelines recommend palliative care approaches for many serious illnesses, the palliative needs of patients with serious illnesses other than cancer are often unmet, mainly due to insufficient prognosis-related discussion. We investigated physicians' and the general public's respective attitudes toward prognostic disclosure for several serious illnesses.

METHODS

We conducted a cross-sectional survey of 928 physicians, sourced from 12 hospitals and the Korean Medical Association, and 1,005 members of the general public, sourced from all 17 administrative divisions in Korea.

RESULTS

For most illnesses, most physicians (adjusted proportions - end-organ failure, 99.0%; incurable genetic or neurologic disease, 98.5%; acquired immune deficiency syndrome [AIDS], 98.4%; stroke or Parkinson's disease, 96.0%; and dementia, 89.6%) and members of the general public (end-organ failure, 92.0%; incurable genetic or neurologic disease, 92.5%; AIDS, 91.5%; stroke or Parkinson's disease, 92.1%; and dementia, 86.9%) wanted to be informed if they had a terminal prognosis. For physicians and the general public, the primary factor to consider when disclosing terminal status was "the patient's right to know his/her condition" (31.0%). Yet, the general public was less likely to prefer prognostic disclosure than physicians. Particularly, when their family members were patients, more than 10% of the general public did not want patients to be informed of their terminal prognosis. For the general public, the main reason for not disclosing prognosis was "psychological burden such as anxiety and depression" (35.8%), while for the physicians it was "disclosure would have no beneficial effect" (42.4%).

CONCLUSION

Most Physicians and the general public agreed that disclosure of a terminal prognosis respects patient autonomy for several serious illnesses. The low response rate of physicians might limit the generalizability of the results.

A study protocol for the development of a multivariable model predicting 6- and 12-month mortality for people with dementia living in residential aged care facilities (RACFs) in Australia

BACKGROUND

For residential aged care facility (RACF) residents with dementia, lack of prognostic guidance presents a significant challenge for end of life care planning. In an attempt to address this issue, models have been developed to assess mortality risk for people with advanced dementia, predominantly using long-term care minimum data set (MDS) information from the USA. A limitation of these models is that the information contained within the MDS used for model development was not collected for the purpose of identifying prognostic factors. The models developed using MDS data have had relatively modest ability to discriminate mortality risk and are difficult to apply outside the MDS setting. This study will aim to develop a model to estimate 6- and 12-month mortality risk for people with dementia from prognostic indicators recorded during usual clinical care provided in RACFs in Australia.

METHODS

A secondary analysis will be conducted for a cohort of people with dementia from RACFs participating in a cluster-randomized trial of a palliative care education intervention (IMPETUS-D). Ten prognostic indicator variables were identified based on a literature review of clinical features associated with increased mortality for people with dementia living in RACFs. Variables will be extracted from RACF files at baseline and mortality measured at 6 and 12 months after baseline data collection. A multivariable logistic regression model will be developed for 6- and 12-month mortality outcome measures using backwards elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of the model for 6- and 12-month mortality will be presented as receiver operating curves with c statistics. Calibration curves will be presented comparing observed and predicted event rates for each decile of risk as well as flexible calibration curves derived using loess-based functions.

DISCUSSION

The model developed in this study aims to improve clinical assessment of mortality risk for people with dementia living in RACFs in Australia. Further external validation in different populations will be required before the model could be developed into a tool to assist with clinical decision-making in the future.

Palliative care for nursing home patients with dementia: service evaluation and risk factors of mortality

Background

Difficulties in prognostication are common deterrents to palliative care among dementia patients. This study aimed to evaluate the effectiveness of palliative care in reducing the extent of utilization of medical services and the potential risk factors of mortality among dementia patients receiving palliative care.

Methods

We surveyed dementia patients involved in a palliative care program at a long-term care facility in Taipei, Taiwan. We enrolled 57 patients with advanced dementia (clinical dementia rating ≥ 5 or functional assessment staging test stage 7b). We then compared the extent of their utilization of medical services before and after the provision of palliative care. Based on multivariable logistic regression, we identified potential risk factors before and after the provision of palliative care associated with 6-month mortality.

Results

The utilization of medical services was significantly lower among dementia patients after the provision of palliative care than before, including visits to medical departments (p < 0.001), medications prescribed (p < 0.001), frequency of hospitalization (p < 0.001), and visits to the emergency room (p < 0.001). Moreover, patients dying within 6 months after the palliative care program had a slightly but not significantly higher number of admissions before receiving hospice care (p = 0.058) on univariate analysis. However, no significant differences were observed in multivariate analysis.

Conclusions

The provision of palliative care to dementia patients reduces the extent of utilization of medical services. However, further studies with larger patient cohorts are required to stratify the potential risk factors of mortality in this patient group.

Nursing Staff Needs in Providing Palliative Care for Persons With Dementia at Home or in Nursing Homes: A Survey

PURPOSE

This study aimed to evaluate what types and forms of support nursing staff need in providing palliative care for persons with dementia. Another aim was to compare the needs of nursing staff with different educational levels and working in home care or in nursing homes.

DESIGN

A cross-sectional, descriptive survey design was used.

METHODS

A questionnaire was administered to a convenience sample of Dutch nursing staff working in the home care or nursing home setting. Data were collected from July through October 2018. Quantitative survey data were analyzed using descriptive statistics. Data from two open-ended survey questions were investigated using content analysis.

FINDINGS

The sample comprised 416 respondents. Nursing staff with different educational levels and working in different settings indicated largely similar needs. The highest-ranking needs for support were in dealing with family disagreement in end-of-life decision making (58%), dealing with challenging behaviors (41%), and recognizing and managing pain (38%). The highest-ranking form of support was peer-to-peer learning (51%). If respondents would have more time to do their work, devoting personal attention would be a priority.

CONCLUSIONS

Nursing staff with different educational levels and working in home care or in nursing homes endorsed similar needs in providing palliative care for persons with dementia and their loved ones.

CLINICAL RELEVANCE

It is critical to understand the specific needs of nursing staff in order to develop tailored strategies. Interventions aimed at increasing the competence of nursing staff in providing palliative care for persons with dementia may target similar areas to support a heterogeneous group of nurses and nurse assistants, working in home care or in a nursing home.

Palliative Care in Advanced Dementia

Dementia syndrome is common and expected to increase significantly among older people and characterized by the loss of cognitive, psychological and physical functions. Palliative care is applicable for people with dementia, however they are less likely to have access to palliative care. This narrative review summarizes specifics of palliative care in advanced dementia. Most people with advanced dementia live and die in institutional care and they suffer a range of burdensome symptoms and complications. Shortly before dying people with advanced dementia suffer symptoms as pain, eating problems, breathlessness, neuropsychiatric symptoms, and complications as respiratory or urinary infections and frequently experience burdensome transitions. Pharmacological and nonpharmacological interventions may reduce symptom burden. Sensitive observation and appropriate assessment tools enable health professionals to assess symptoms and needs and to evaluate interventions. Due to lack of decisional capacity, proxy decision making is often necessary. Advanced care planning is an opportunity establishing values and preferences and is associated with comfort and decrease of burdensome interventions. Family carers are important for people with advanced dementia they also experience distress and are in need for support. Recommendations refer to early integration of palliative care, recognizing signs of approaching death, symptom assessment and management, advanced care planning, person-centered care, continuity of care, and collaboration of health care providers.

Factors influencing palliative care in advanced dementia: a systematic review

Background

Dementia is a progressive neurodegenerative life-limiting disease. The international literature indicates that patients with advanced dementia can benefit from palliative care (PC) provided during the end-of-life phase. However, evidence indicates that currently many fail to access such provision despite the increased recognition of their palliative needs.

Aim

To investigate the factors influencing provision of PC services for people with advanced dementia.

Methods

A systematic review of mixed method studies written in English was undertaken. 11 electronic databases including Embase, Medline, PubMed, CINAHL and Scopus from 2008 to 2018 were searched. Narrative synthesis and content analysis were used to analyse and synthesise the data.

Key findings

In total, 34 studies were included. 25 studies providing qualitative data, 6 providing quantitative data and 3 mixed methods studies. The findings identified organisational, healthcare professionals and patients-related barriers and facilitators in provision of PC for people with advanced dementia from perspective of stakeholders across different care settings. The most commonly reported barriers are lack of skills and training opportunities of the staff specific to PC in dementia, lack of awareness that dementia is a terminal illness and a palliative condition, pain and symptoms assessment/management difficulties, discontinuity of care for patients with dementia and lack of coordination across care settings, difficulty communicating with the patient and the lack of advance care planning.

Conclusions

Even though the provision of PC was empirically recognised as a care step in the management of dementia, there are barriers that hinder access of patients with dementia to appropriate facilities. With dementia prevalence rising and no cure on the horizon, it is crucial that health and social care regulatory bodies integrate a palliative approach into their care using the identified facilitators to achieve optimal and effective PC in this population.