What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death

Symptom burden, service use and care dissatisfaction among older adults with cancer, cardiovascular disease, respiratory disease, dementia and neurological disease during the last 3 months before death: A pooled analysis of mortality follow-back surveys

BACKGROUND

Variation in the provision of care and outcomes in the last months of life by cancer and non-cancer conditions is poorly understood.

AIMS

(1) To describe patient conditions, symptom burden, practical problems, service use and dissatisfaction with end-of-life care for older adults based on the cause of death. (2) To explore factors related to these variables focussing on the causes of death.

DESIGN

Secondary analysis of pooled data using cross-sectional mortality follow-back surveys from three studies: QUALYCARE; OPTCare Elderly; and International Access, Right, and Empowerment 1.

SETTING/PARTICIPANTS

Data reported by bereaved relatives of people aged ⩾75 years who died of cancer, cardiovascular disease, respiratory disease, dementia or neurological disease.

RESULTS

The pooled dataset contained 885 responses. Overall, service use and circumstances surrounding death differed significantly across causes of death. Bereaved relatives reported symptom severity from moderate to overwhelming in over 30% of cases for all causes of death. Across all causes of death, 28%-38% of bereaved relatives reported some level of dissatisfaction with care. Patients with cardiovascular disease and dementia experienced lower symptom burden and dissatisfaction than those with cancer. The absence of a reliable key health professional was consistently associated with higher symptom burden (p = 0.002), practical problems (p = 0.001) and dissatisfaction with care (p = 0.001).

CONCLUSIONS

We showed different trajectories towards death depending on cause. Improving symptom burden and satisfaction in patients at the end-of-life is challenging, and the presence of a reliable key health professional may be helpful.

Older Adults' Unmet Needs at the End of Life: A Cross-Country Comparison of the United States and England

Objectives: This study aimed to compare the end-of-life (EOL) experiences in concentration with place of death, for older adults in the U.S. and England. Methods: Weighted comparative analysis was conducted using harmonized Health and Retirement Study and English Longitudinal Study of Ageing datasets covering the period of 2006-2012. Results: At the EOL, more older adults in the U.S. (64.14%) than in England (54.09%) had unmet needs (I/ADLs). Home was the main place of death in the U.S. (47.34%), while it was the hospital in England (58.01%). Gender, marital status, income, place of death, previous hospitalization, memory-related diseases, self-rated health, and chronic diseases were linked to unmet needs in both countries. Discussion: These findings challenge the existing assumptions about EOL experiences and place of death outcomes, emphasizing the significance of developing integrated care models to bolster support for essential daily activities of older adults at the EOL.

Telephone advice lines for adults with advanced illness and their family carers: a qualitative analysis and novel practical framework

BACKGROUND

Telephone advice lines have been recommended internationally to support around-the-clock care for people living at home with advanced illness. While they undoubtedly support care, there is little evidence about what elements are needed for success. A national picture is needed to understand, improve and standardise service delivery/care.

AIM

To explore telephone advice lines for people living at home with advanced illness across the four UK nations, and to construct a practical framework to improve services.

DESIGN

A cross-national evaluation of telephone advice lines using structured qualitative interviews. A patient and public involvement workshop was conducted to refine the framework.

SETTING/PARTICIPANTS

Professionals with responsibilities for how palliative care services are delivered and/or funded at a local or regional level, were purposively sampled.

RESULTS

Seventy-one interviews were conducted, covering 60 geographical areas. Five themes were identified. Availability: Ten advice line models were described. Variation led to confusion about who to call and when. Accessibility, awareness and promotion: It was assumed that patients/carers know who to call out-of-hours, but often they did not. Practicalities: Call handlers skills/expertise varied, which influenced how calls were managed. Possible responses ranged from signposting to organising home visits. Integration/continuity of care: Integration between care providers was limited by electronic medical records access/information sharing. Service structure/commissioning: Sustained funding was often an issue for charitably funded organisations.

CONCLUSIONS

Our novel evidence-based practical framework could be transformative for service design/delivery, as it presents key considerations relating to the various elements of advice lines that may impact on the patient/carer experience.

Trends in the place of death in Sweden from 2013 to 2019 - disclosing prerequisites for palliative care

Background

The drive for home care has increasingly impacted the organization and allocation of resources within the Swedish healthcare system.

Objectives

With an interest in uncovering prerequisites for palliative care, this study aimed to investigate longitudinal trends in place of death within the adult Swedish population from 2013 to 2019 and examine potential associations between place of death and individual, geographic, and socioeconomic factors; hospital capacity; and healthcare utilization.

Methods

This population-level comprehensive register study included all deceased individuals ⩾18 years old with a registered place of death (n = 599,137). Data were retrieved from public and patient data registers and the national register for palliative care. Trends and associations between place of death and co-variables were investigated by logistic regression- and interaction analyses.

Results

From 2013 to 2019, the total number of home deaths increased by 1.9%, whereas the number of hospital deaths decreased by 2.6%. In the overall population of individuals living in their own homes, from 2013 to 2019, the likelihood of dying in hospital versus dying at home decreased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Within the population with potential palliative needs living in their own home (78.4%), the likelihood of dying in hospitals equally decreased, except in Stockholm and the north region. For individuals residing in a nursing home, however, the likelihood of dying in hospital versus remaining in the nursing home until death only significantly decreased in the southern region.

Conclusion

The results show a trend towards a decrease in hospital deaths but with cross-regional variations. Still, in 2019, only about one-fifth of all individuals died in their own homes. Public health-oriented interventions aimed at strengthening palliative care resources in nursing homes and home care are suggested.

Palliative care in a Graduate Entry Medical Curriculum: exploring students' attitudes on the importance of receiving teaching in palliative care

BACKGROUND

As people live longer with life-limiting illnesses, there is greater need for skills and knowledge in palliative care (PC). Medical students should acquire the knowledge, attitudes, and confidence during training for future decision-making. However, most graduates across Europe feel unprepared to provide PC. To develop PC training for medical students, we must gain perspective on their understanding of PC and their learning needs.

OBJECTIVES

The aim was to investigate graduate entry medical students' views on the importance of education in PC and how well PC topics were covered within their curriculum. The objective was to highlight areas that could be reviewed for future PC curricula.

METHODS

In this prospective quantitative study, penultimate and final-year students were recruited from a graduate entry medical school. Ethical approval was granted. Students completed an online questionnaire.

RESULTS

From 281 recruited students, 82 responded. Ninety-five percent of respondents felt everyone should have a PC rotation. The aspects of education perceived to be most important were knowledge of symptom control, communication, ethical issues, self-care, and grief. The only aspect considered well covered within the curriculum was ethical issues. Ninety-six percent of penultimate and 75% of final years wanted more teaching in PC.

CONCLUSION

Graduate entry medical students view PC as a vital subject within their medical school training. The study highlights challenges in providing education and sufficient placement in PC to correlate with the respondents' perceived needs. The findings contribute to the growing literature surrounding the importance of PC education within the medical school curriculum.

Video training of nursing home healthcare workers in palliative care

OBJECTIVES

The provision of palliative care in nursing homes (NHs) is of paramount importance, a realism underscored by the frailty and medical complexity of the residents. However, palliative care (PC) education tends to be resource-intensive both for educators and healthcare workers (HCWs). The aim of this study was to investigate how PowerFacts, a video animation series that taught basic PC to NH HCWs in Singapore impacted their knowledge, attitudes and confidence.

METHODS

A cohort study design was adopted for the study. A total of 264 NH HCWs across 12 NHs in Singapore participated in the study from January 2021 to October 2022. Participants were assessed using a 20-summative multiple-choice question assessment, a 30-item Frommelt Attitude Toward Care of the Dying Scale (FATCOD) and four questions on their confidence level before and after the PowerFacts course.

RESULTS

Paired t-test was performed. Significant changes were noted in the knowledge and confidence score post-intervention. The knowledge score improved significantly from preintervention (12.2±3.5) to post-intervention (15.8±3.4; p<0.01). The confidence score increased significantly from 14.7±2.7 to 16.7±2.2 (p<0.01). However, the FATCOD score did not reveal any significant changes between preintervention and post-intervention results (p>0.05).

CONCLUSIONS

PowerFacts has demonstrated its potential as a valuable addition to the array of teaching methods available to NH HCWs. Future studies are required to evaluate the impact of animation on patient care and clinical practice.

Development and implementation of the Specialist Palliative Care in Aged Care (SPACE) Project across Queensland

There is an urgent and unmet need for specialist palliative care services in residential aged care. The Specialist Palliative Care in Aged Care (SPACE) Project aimed to improve palliative and end-of-life care for older people living in residential aged care facilities in Queensland. A representative working group developed a series of service principles around palliative care practice in aged care (comprehensive resident-focused care, streamlined service, and capacity building). Funding was allocated by population to the health services in Queensland to adapt and implement models of care aligned with these principles. SPACE successfully implemented a variety of decentralised models of care across Queensland. The critical elements for the success of SPACE were the use of an expert working group to define the core innovation, networking and implementation support from the central project team and community of practice, and adaptable models of care led by local facilitators. Lessons learned from this real-world case study could be adopted to guide and ensure the successful implementation and sustainability of future complex interventions in healthcare settings, both nationally and internationally.

Advanced heart failure: parenteral diuretics for breathlessness and peripheral oedema - systematic review

BACKGROUND

Advanced heart failure patients suffer with breathlessness and peripheral oedema, which are frequently treated with parenteral diuretics despite limited evidence.

AIM

To analyse the effectiveness of parenteral diuretics on breathlessness and peripheral oedema in advanced heart failure patients.

METHODS

We searched Embase, MEDLINE(R), PsycINFO, CINAHL and CENTRAL from their respective inceptions to 2021, and performed handsearching, citation searching and grey literature search; limited to English publications. Selection criteria included parenteral (intravenous/subcutaneous) diuretic administration in advanced heart failure patients (New York Heart Association class III-IV). Two authors independently assessed articles for inclusion; one author extracted data. Data were synthesised through narrative synthesis or meta-analysed as appropriate.

RESULTS

4646 records were screened; 6 trials (384 participants) were included. All were randomised controlled trials (RCTs) comparing intravenous continuous furosemide infusion (CFI) versus intravenous bolus furosemide infusion (BFI). Improvement in breathlessness and peripheral oedema (two studies, n=161, OR 2.80, 95% CI 1.45 to 5.40; I2=0%), and increase in urine output (four studies, n=234, mean difference, MD 344.76, 95% CI 132.87 to 556.64; I2=44%), were statistically significant in favour of CFI. Significantly lower serum potassium was found in BFI compared with CFI (three studies, n=194, MD -0.20, 95% CI -0.38 to -0.01; I2=0%). There was no difference between CFI and BFI on reduction in weight, renal function or length of hospital stay.

CONCLUSIONS

CFI appears to improve congestion in advanced heart failure patients in the short term. Available data came from small trials. Larger, prospective RCTs are recommended to address the evidence gap.

EOLinPLACE: an international research project to reform the way dying places are classified and understood

Background

Whenever possible, a person should die where they feel it is the right place to be. There is substantial global variation in home death percentages but it is unclear whether these differences reflect preferences, and there are major limitations in how the place of death is classified and compared across countries.

Objectives

EOLinPLACE is an international interdisciplinary research project funded by the European Research Council aiming to create a solid base for a ground-breaking international classification tool that will enable the mapping of preferred and actual places towards death.

Design

Mixed-methods observational research.

Methods and analysis

We combine classic methods of developing health classifications with a bottom-up participatory research approach, working with international organizations representing patients and informal carers [International Alliance of Patients' Organizations (IAPO) and Eurocarers]. First, we will conduct an international comparative analysis of existing classification systems and routinely collected death certificate data on place of death. Secondly, we will conduct a mixed-methods study (ethnography followed by longitudinal quantitative study) in four countries (the Netherlands, Portugal, Uganda and the United States), to compare the preferences and experiences of patients with life-threatening conditions and their families. Thirdly, based on the generated evidence, we will build a contemporary classification of dying places; assess its content validity through focus groups with patients, carers and other stakeholders; and evaluate it in a psychometric study to examine construct validity, reliability, responsiveness, data quality and interpretability.

Ethics

Approved by the ethics committee of the University of Coimbra, Faculty of Medicine (CE-068-2022) and committees in each of the participating countries.

Discussion

The findings will provide a deeper understanding of the diversity in individual end-of-life pathways. They will enable key developments such as measurement of progress towards achievement of preferences when care can be planned. The project will open new directions in how to care for the dying.

Trial registration

Research Registry UIN 9213.

Factors Associated with Hospitalized Community-Acquired Pneumonia among Elderly Patients Receiving Home-Based Care

(1) Background: Pneumonia stands as a prevalent infectious disease globally, contributing significantly to mortality and morbidity rates. In Taiwan, pneumonia ranks as the third leading cause of death, particularly affecting the elderly population (92%). This study aims to investigate factors associated with community-acquired pneumonia (CAP) among elderly individuals receiving home-based care. (2) Methods: Conducted between January 2018 and December 2019, this retrospective study involved a medical chart review of elderly patients under home-based care. A multiple logistic regression model was employed to identify factors associated with CAP in this demographic. (3) Results: Analysis encompassed 220 elderly patients with an average age of 82.0 ± 1.1 years. Eighty-five patients (38.6%) were hospitalized for CAP. Predominant diagnoses included cancer (32.3%), stroke (24.5%), and dementia (23.6%). Significant predictors of CAP for elderly patients under home-based care included male gender (odds ratio [OR] = 4.10, 95% confidence interval [CI]: 1.95-8.60, p < 0.001), presence of a nasogastric (NG) tube (OR = 8.85, 95% CI: 3.64-21.56, p < 0.001), and a borderline negative association with the use of proton pump inhibitors (PPIs) (OR = 0.37, 95% CI: 0.13-1.02, p = 0.0546). End-of-life care indicators for these patients with CAP included an increased number of hospital admission days in the last month of life (OR = 1.13, 95% CI: 1.08-1.18, p < 0.001) and a higher likelihood of hospital death (OR = 3.59, 95% CI: 1.51-8.55, p = 0.004). (4) Conclusions: In the current study, significant predictors of CAP among elderly patients receiving home-based care included the presence of an NG tube and male gender, while the use of PPIs was borderline inversely associated with the risk of CAP. Notably, more admission days in the last month of life and death in the hospital were found to be associated with end-of-life care for this group.

Developing a best-practice agenda for music therapy research to support informal carers of terminally ill patients pre- and post-death bereavement: a world café approach

BACKGROUND

Informal carers of terminally ill patients play a vital role in providing palliative care at home, which impacts on their pre- and post-death bereavement experience and presents an up to 50% greater risk for mental-health problems. However, developing and implementing effective bereavement support remains challenging. There is a need to build the evidence base for music therapy as a potentially promising bereavement support for this vulnerable population. This study aimed to co-design an international best practice agenda for research into music therapy for informal carers of patients pre- and post-death bereavement.

METHODS

Online half day workshop using a World Café approach; an innovative method for harnessing group intelligence within a group of international expert stakeholders (music therapy clinicians and academics with experience of music therapy with informal carers at end-of-life). Demographics, experience, key priorities and methodological challenges were gathered during a pre-workshop survey to inform workshop discussions. The online workshop involved four rounds of rotating, 25-minute, small group parallel discussions using Padlet. One final large group discussion involved a consensus building activity. All data were analysed thematically to identify patterns to inform priorities and recommendations.

RESULTS

Twenty-two consented and completed the pre-event survey (response rate 44%), from countries representing 10 different time zones. Sixteen participated in the workshop and developed the following best practice agenda. The effectiveness of music therapy in supporting informal carers across the bereavement continuum should be prioritised. This should be done using a mixed methods design to draw on the strengths of different methodological approaches to building the evidence base. It should involve service users throughout and should use a core outcome set to guide the choice of clinically important bereavement outcome measures in efficacy/effectiveness research.

CONCLUSIONS

Findings should inform future pre- and post-death bereavement support research for informal caregivers of terminally ill patients. This is an important step in building the evidence base for commissioners and service providers on how to incorporate more innovative approaches in palliative care bereavement services.

Leveraging Clinical Informatics to Address the Quintuple Aim for End-of-Life Care

As the population of older adults grows at an unprecedented rate, there is a large gap to provide culturally tailored end-of-life care. This study describes a payor-led, informatics-based approach to identify Medicare members who may benefit from a Compassionate CareSM Program (CCP), which was designed to provide specialized care management services and support to members who have end-stage and/or life-limiting illnesses by addressing the quintuple aim. Potential participants are identified through machine learning models whereby nurse care managers then provide tailored outreach via telephone. A retrospective, observational cohort analysis of propensity-weighted Medicare members was performed to compare decedents who did or did not participate in the CCP. This program enhanced the end-of-life care experience while providing equitable outcomes regardless of age, gender, and geography and decreased inpatient (-37%) admissions with concomitant reduced (-59%) medical spend when compared to decedents that did not utilize the end-of-life care management program.

Practicalities of promoting practice-based learning in end of life care for care home staff: Lessons from "online" supportive conversations and reflection sessions

INTRODUCTION

Deaths in care homes and "at home" are anticipated to account for a third of UK deaths by 2040. Currently, palliative and end of life care are not part of statutory training in care homes. Reflective practice is a tool that can facilitate practice-based learning and support. Following a feasibly study to test "online" supportive conversations and reflection sessions (OSCaRS) to support care home staff in relation to death/dying during the first months of the COVID pandemic, a one-year practice development follow-up project was undertaken with the aim to create a team of NHS/specialist palliative care (SPC)-based facilitators to lead and support OSCaRS provision in up to 50 care homes in one region in Scotland-the focus of this paper.

METHODS

Forty care home managers attended an on-line session explaining the project, with a similar session held for 19 NHS/SPC-based nurses external to care homes. Those interested in facilitating OSCaRS then attended three education sessions.

DATA COLLECTED

records of all activities; reflective notes on OSCaRS organised/delivered; a summary of each OSCaRS reflection/learning points; final interviews with NHS/SPC trainee facilitators.

RESULTS

A total of 19 NHS/SPC facilitators delivered one or more OSCaRS in 22 participating care homes. However, as of January 2022 only six trained facilitators remained active. Out of the 158 OSCaRS arranged, 96 took place with a total of 262 staff attending. There were three important aspects that emerged: the role, remit, and resources of NHS/SPC supporting OSCaRS; requirements within care homes for establishing OSCaRS; and, the practice-based learning topics discussed at each OSCaRS.

CONCLUSION

Attempts to establish a team of NHS/SPC facilitators to lead OSCaRS highlights that end of life care education in care homes does not clearly fall within the contractual remit of either group or risks being missed due to more pressing priorities.

Impact of home-visit nursing service use on costs in the last 3 months of life among older adults: A retrospective cohort study

INTRODUCTION

Considering Japan's aging society, the number of older individuals who die at home is expected to increase. In Japan, there are challenges in utilizing and promoting home-visit nursing services at the end of life for community-dwelling older adults. We examined the use of home-visit nursing services at the end of patients' lives and the recommended use patterns of this service (utilization, timing of initiation, and continuity) that contribute to reducing the medical care and long-term care costs (total costs) in the last 3 months of life.

DESIGN

This was a retrospective cohort study.

METHODS

We examined 33 municipalities in Japan, including depopulated areas. The analysis included 22,927 people aged 75 or older who died between September 2016 and September 2018. We used monthly medical care and long-term care insurance claims data. Participants were classified into five groups based on their history of home-visit nursing service use: (1) early initiation/continuous use, (2) early initiation/discontinued or fragment use, (3) not-early initiation/continuous use, (4) not-early initiation/fragment use, and (5) no use. Univariate and multivariate linear regression analyses were performed to examine the association between total costs in the last 3 months of life and patterns of home-visit nursing service use.

RESULTS

Overall, the median age was 85, and 12,217 participants were men (53.3%). In the last half year before death, 5424 (23.7%) older adults used home-visit nursing services. Multivariable linear regression analysis of the log10-transformed value of total costs revealed that compared with the no use group, the early initiation/continuous use group was estimated to have 0.88 times (95% confidence interval: 0.84, 0.93) the total costs in the last 3 months of life (p < 0.001).

CONCLUSION

Early initiation use of home-visit nursing services may contribute to reducing total costs in the last 3 months of life for Japanese people aged 75 years or older living at home as they approach the end of life.

CLINICAL RELEVANCE

When approaching the end of life, many older adults require daily life care and palliative care. Policymakers are strengthening end-of-life care for community-dwelling older adults in Japan. Although the current results do not demonstrate the effectiveness of home-visit nursing services, they provide a perspective from which to assess the use of home-visit nursing services and its impact on older adults. The findings can be helpful in considering how to provide nursing care in home-care settings for older adults who prefer to spend their final days at home.

Understanding experiences of the radiography workforce delivering medical imaging as part of patients' end of life care: An exploratory qualitative interview study

INTRODUCTION

People nearing the end of life often require medical imaging in hospitals to manage symptoms and care, despite this little is known about the experiences of those delivering it. The aim of this study is therefore to explore the experiences of the radiography workforce delivering medical imaging as part of patients' end-of-life care.

METHOD

Qualitative design using semi-structured interviews and thematic analysis. A total of 8 participants participated in the study including registered diagnostic radiographers (n = 5), imaging assistants (n = 2) and assistant practitioners (n = 1). All have been involved in the medical imaging of patients receiving end of life care in UK hospitals.

RESULTS

Findings identified an absence of end of life care policy guidance and education accessible to radiography staff, limiting their ability to provide evidenced based care for those nearing the end of life during medical imaging examinations. Findings also suggest difficulty in identifying patients receiving end of life care further hindered staffs' ability to adapt their care to provide a more person-centred approach. Lastly, the workforce felt an accumulative emotional burden following their interactions with patients nearing the end of life.

CONCLUSION

There is a clear need to develop policy and education to support the radiography workforce to ensure care is appropriately identified and adapted to those nearing the end of life. Furthermore, staff support and wellbeing needs to be considered.

IMPLICATIONS FOR PRACTICE

Future research is required exploring the patient perspective to understand their experiences so that the education and practice provision is driven by patient need. International exploration of end of life care in medical imaging is recommended to explore whether similar challenges related to clinical practice exist in other countries.

Non-pharmacological interventions in primary care to improve the quality of life of older patients with palliative care needs: a systematic review of randomised controlled trials

OBJECTIVES

Our systematic review aimed to summarise non-pharmacological interventions applicable in primary care that improve the quality of life of older patients with palliative care needs.

DESIGN

Systematic review.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was patients' quality of life. Secondary outcomes were symptoms relief and patients' well-being measures.

METHODS AND ANALYSIS

We searched MEDLINE, EMBASE, PsycINFO, Cochrane and CINAHL up to October 2022 for randomised controlled trials (RCTs). We also handsearched abstract books of relevant congresses and scientific meetings in the last 5 years. Screening, data extraction and quality evaluation (Cochrane risk-of-bias (RoB) V.2.0 tool and Grading of Recommendations, Assessment, Development and Evaluations (GRADE)) were done independently by two reviewers, with disagreements solved by a third reviewer. Findings were narratively synthesised.

RESULTS

We identified 4 RCTs, including 268 patients. One study used a broad criteria of palliative care needs ('progressive, life-threatening disease'), two studies focused on advanced cancer and one study on heart failure. The non-pharmacological interventions evaluated were advance care planning conducted by general practitioners (GPs); social worker-aided palliative care; online primary palliative care training for GPs and spiritual history taking by nurses and GPs. No intervention showed a statistically significant impact on quality of life and the evidence was low according to GRADE.

CONCLUSION

The results highlight a dearth of evidence on what non-pharmacological interventions can be effectively done in primary care to improve the quality of life of older persons with palliative care needs. The results should be interpreted with caution, as the search more comprehensively covers interventions delivered by GPs.

PROSPERO REGISTRATION NUMBER

CRD42020154216.

Family Carers' Experiences of Goals of Care Conversations in Acute Hospital Settings

End-of-life Goals of Care (GoC) discussions aim to support care that is consistent with patients' preferences and values. This study uses an exploratory qualitative design drawing upon a social constructivist epistemology to examine family carers' perspectives on GoC within acute Australian hospital settings. Twenty-five family carers of aging inpatients were recruited from six Australian hospitals to participate in recorded, semi-structured interviews. Data were transcribed and analyzed using reflexive thematic analysis. Three main themes were developed. Theme 1 explored carers' experiences of GoC discussions-identifying varying levels of preparedness and carers' hopes for open, two-way discussions initiated by empathic Health Care Professionals (HCPs). Theme 2 examined carers' unmet needs for time, space, consistency, and support to make careful decisions. Theme 3 identified carers advocating for patients' needs when they could not do it themselves. Preparing carers and normalizing GoC discussions relating to end-of-life care maximizes benefits for patients, carers, and HCPs involved.

Validation of a culturally adapted Swedish-language version of the Death Literacy Index

The death literacy index (DLI) was developed in Australia to measure death literacy, a set of experience-based knowledge needed to understand and act on end-of-life (EOL) care options but has not yet been validated outside its original context. The aim of this study was to develop a culturally adapted Swedish-language version of the DLI, the DLI-S, and assess sources of evidence for its validity in a Swedish context. The study involved a multi-step process of translation and cultural adaptation and two validation phases: examining first content and response process validity through expert review (n = 10) and cognitive interviews (n = 10); and second, internal structure validity of DLI-S data collected from an online cross-sectional survey (n = 503). The psychometric evaluation involved analysis of descriptive statistics on item and scale-level, internal consistency and test-retest reliability, and confirmatory factor analysis. During translation and adaptation, changes were made to adjust items to the Swedish context. Additional adjustments were made following findings from the expert review and cognitive interviews. The content validity index exceeded recommended thresholds (S-CVIAve = 0.926). The psychometric evaluation provided support for DLI-S' validity. The hypothesized six-factor model showed good fit (χ2 = 1107.631 p<0.001, CFI = 0.993, TLI = 0.993, RMSEA = 0.064, SRMR = 0.054). High internal consistency reliability was demonstrated for the overall scale (Cronbach's α = 0.94) and each sub-scale (α 0.81-0.92). Test-retest reliability was acceptable, ICC ranging between 0.66-0.85. Through a comprehensive assessment of several sources of evidence, we show that the DLI-S demonstrates satisfactory validity and acceptability to measure death literacy in the Swedish context. There are, however, indications that the sub-scales measuring community capacity perform worse in comparison to other sca and may function differently in Sweden than in the original context. The DLI-S has potential to contribute to research on community-based EOL interventions.

Ethical Leadership in LTC: From Caregivers' Customer Orientation to Senior's Satisfaction and Well-Being

Background

In response to the growth of the world's senior population, an investigation of ethical leadership on LTCs is needed, in particular in the impact it may have on customer orientation and on seniors' well-being.

Objective

We propose a model to identify the relationship between ethical leadership in LTCs and caregivers' customer orientation, and its influence on satisfaction with the service, satisfaction with life, and the quality of the interaction between caregivers and seniors.

Sampling

We present a matched sample of 277 caregivers and 277 elderly Brazilians, workers and seniors' in LTCs in Brazil. The minimum sample size was 222, determined using G-Power software version 3.1.9.2, based on the desired statistical power parameters and the number of predictors. Two structured questionnaires were developed, one for caregivers and the other for the elderly. 69 LTCs were contacted and 29 participated in the survey (10 nonprofit, 34.48%). Data were treated statistically using SEM modelling.

Results

We identified a positive influence of ethical leadership on caregivers' attitudes, favoring their orientation towards the seniors'. A positive relationship between customer-oriented caregivers and customer satisfaction, life satisfaction, and the quality of the senior's interaction. A customer-oriented caregiver exerts a mediating effect between ethical leadership and the seniors' related outcomes, making ethical leadership beneficial to seniors and their family members.

Conclusion

Ethical leadership favors successful management of LTCs, increasing customer orientation, and provides clues to establish a better causality and a chain of effects between leadership and senior-related outcomes. Therefore, LTCs may be the appropriate outlet for the role of ethics in leadership.

Practical Implications

This study provides managers with an understanding of the effects of ethical leadership in the context of LTCs, for both caregivers and seniors. The powerful effects of ethical leadership can be a stimulus to increase the role of ethics in LTCs, improving the quality of care, the well-being of the seniors, and, therefore, the human and financial performance of these institutions.

Psychosocial burdens in palliative care - a longitudinal cohort study in nursing homes and impacts of the COVID-19 pandemic

BACKGROUND

In Germany, palliative care in nursing homes is becoming increasingly important. Simultaneously, nursing homes are particularly affected by the COVID-19 pandemic due to their vulnerable residents leading to increased burdens for nursing staff. Although a separate unit for palliative care may not be present in nursing homes as it is in, e.g., hospitals, palliative care occupies a large portion of the workday in nursing homes. As no study addressing this topic could be found, this study focused on the research questions of how the psychosocial burdens faced by nursing staff in palliative care have been affected by the COVID-19 pandemic and how those burdens differ from the psychosocial burdens encountered in general care.

METHODS

Basen on a longitudinal cohort study design, a total of 113 nurses, nursing assistants and caregivers drawn from two nursing homes in North Rhine-Westphalia, Germany, were surveyed pre-pandemic in 2019 and during the pandemic in 2022 using the Copenhagen Psychosocial Questionnaire (COPSOQ) III. Data were examined descriptively following the standardised COPSOQ procedure. Additionally, chi-squared test was conducted to investigate the homogeneity between the groups. Mean differences (MD) were provided and Cohen's d was calculated to evaluate relevant differences in psychosocial burdens between 2019 and 2022. In a second step, t-tests were performed to test statistical significance.

RESULTS

Relevant positive changes could be identified in 'Quantitative demands' (d = 0.321; MD = 5.9), 'Influence at work' (d = 0.244; MD = 5.4), 'Job insecurity' (d = 0.321; MD = 6.5), 'Insecurity over working conditions' (d = 0.296; MD = 6.8), 'Burnout symptoms related to residents' (d = 0.201; MD = 3.8), 'Degrees of freedom' (d = 0.455; MD = 9.6) and 'Presenteeism' (d = 0.425; MD = 11.8). Relevant negative changes were found in 'Dissolution' (d = 0.217; MD = 5.4; i.e., setting boundaries between work and private life), 'Role conflicts' (d = 0.282; MD = 5.5), 'Role clarity' (d = 0.251; MD = 3.3) and 'Burnout symptoms related to relatives' (d = 0.318; MD = 6.0). Relevant changes that were statistically significant according to the t-test could be identified in 'Degrees of freedom' (t-value=-2.40; p = 0.018) and 'Presenteeism' (t-value = 2.26; p = 0.026). Responses to questions concerning nursing homes' handling of the COVID-19 pandemic exhibited a mean score of 68.2 for 'Organisation/communication' and a mean score of 78.1 concerning 'Operational measures and overall assessment' during the COVID-19 pandemic.

CONCLUSIONS

Besides negative changes during the COVID-19 pandemic, some categories showed more positive results. The burdens of palliative care in nursing homes may be perceived differently than those of general care in nursing homes. Furthermore, the results indicate that perceptions of challenges in palliative care in nursing homes during the pandemic seem to be highly dependent on organisational working conditions and support that can strengthen the individual resources and resilience of the staff.

Changes in the Place of Death and Implications for End-of-Life Care Policy: A Population-Based Observational Study

Background: Death in hospital rather than at home is becoming more prevalent, even among terminally ill patients receiving home-based care. Identifying trends in places of death is crucial to care policy, especially for aging populations as in Taiwan. Aim: To identify changes in the places of natural death of Taiwanese individuals for various causes of death. Design: A population-based observational study was conducted. Setting: Anonymous data for the period 2000-2020 from the Death Database of Taiwan's National Center for Health Statistics Data were obtained and analyzed. Results: In 2000, 60.1% of natural deaths occurred in the home, whereas in 2020, this percentage was only 36.8%; conversely, the percentage of deaths in hospital increased from 34.4% in 2000 to 56.1% in 2020. Deaths in a nursing home or long-term care facility were found to account for only 3.8% of all natural deaths in 2020. Dementia was the cause of death for which the proportion of institutional deaths was highest, although this proportion was <10% for most years. We applied the joinpoint regression model to estimate trend changes in places of death. During the study period, the places of death in Taiwan changed significantly, the average annual percent changes for hospital deaths over the 21-year period was 2.54% (confidence interval [CI]: 2.04 to 3.03), and for home deaths was -2.69% (CI: -3.26 to -2.13). Conclusions: The detailed findings of this national study can offer insight into potential future clinical burdens and lead to better health policy decisions for Taiwan.

"I didn't know it was going to be like this.": unprepared for end-of-Life care, the experiences of care aides care in long-term care

BACKGROUND

Care aides provide up to 70-90% of the direct care for residents in long-term care (LTC) and thus hold great potential in improving residents' quality of life and end-of-life (EoL) care experiences. Although the scope and necessity of the care aide role is predicted to increase in the future, there is a lack of understanding around their perceptions and experiences of delivering EoL care in LTC settings. The aim of this study was to gain an understanding of the perspectives, experiences, and working conditions of care aides delivering end-of-life care in LTC in a rural setting, within a high-income country.

METHODS

Data were collected over ten months of fieldwork at one long-term care home in western Canada; semi-structured interviews (70 h) with 31 care aides; and observation (170 h). Data were analysed using Reflexive Thematic Analysis.

RESULTS

Two themes were identified: (i) the emotional toll that delivering this care takes on the care aids and; (ii) the need for healing and support among this workforce. Findings show that the vast majority of care aides reported feeling unprepared for the delivery of the complex care work required for good EoL care. Findings indicate that there are no adequate resources available for care aides' to support the mental and emotional aspects of their role in the delivery of EoL care in LTC. Participants shared unique stories of their own self-care traditions to support their grief, processing and emotional healing.

CONCLUSIONS

To facilitate the health and well-being of this essential workforce internationally, care aides need to have appropriate training and preparation for the complex care work required for good EoL care. It is essential that mechanisms in LTC become mandatory to support care aides' mental health and emotional well-being in this role. Implications for practice highlight the need for greater care and attention played on the part of the educational settings during their selection and acceptance process to train care aides to ensure they have previous experience and societal awareness of what care in LTC settings entails, especially regarding EoL experiences.

'That just doesn't feel right at times' - lone working practices, support and educational needs of newly employed Healthcare Assistants providing 24/7 palliative care in the community: A qualitative interview study

BACKGROUND

Healthcare assistants working in hospice at home settings have a pivotal role in supporting people dying at home and their family caregivers. Some healthcare assistants are working alone in patients' homes, which magnifies some of the issues reported for those working closely with other team members. There is a dearth of evidence in terms of education, training and support needs for healthcare assistants when working alone.

AIM

To explore the role of newly employed lone working healthcare assistants delivering palliative care in the community, and their support and educational needs.

DESIGN

Qualitative exploratory study using semi-structured interviews.

SETTING/PARTICIPANTS

Healthcare assistants (n = 16) employed less than 12 months by a national non-profit hospice and palliative care provider located across the UK.

RESULTS

Analysis of interviews identified three main themes: (1) Healthcare assistants have a unique and complex role catering for holistic needs of patients and their family caregivers in the home environment; (2) preparation for the complex role requires focus on experiential learning and specific training to support holistic care provision; (3) lone workers experience loneliness and isolation and identify peer support as a key intervention to support their wellbeing.

CONCLUSIONS

Given the complexities of their role within community palliative care teams, there are key learning points in relation to healthcare assistant preparation. Education and support networks should be prioritised to reduce isolation and support ongoing learning and development of newly employed healthcare assistants; all of which is vital to ensure safety and quality of care for the growing number of people they support in the community.

Improving paramedic responses for patients dying at home: a theory of change-based approach

BACKGROUND

Paramedics are increasingly being called to attend patients dying from advanced incurable conditions. However, confidence to deal with such calls varies, with many feeling relatively unskilled in this aspect of their role. A number of interventions have been piloted to improve their skills in end-of-life care (EoLC) but without a fully specified theoretical model. Theory of Change models can provide theoretical and testable links from intervention activities to proposed long-term outcomes and indicate the areas for assessment of effectiveness. This study aimed to develop an intervention for improving paramedic EoLC for patients in the community.

METHODS

A Theory of Change approach was used as the overarching theoretical framework for developing an intervention to improve paramedic end-of-life skills. Nine stakeholders - including specialist community paramedics, ambulance call handlers and palliative care specialists - were recruited to five consecutive online workshops, ranging between 60 and 90 min. Each workshop had 2-3 facilitators. Over multiple workshops, stakeholders decided on the desired impact, short- and long-term outcomes, and possible interventions. During and between these workshops a Theory of Change model was created, with the components shared with stakeholders.

RESULTS

The stakeholders agreed the desired impact was to provide consistent, holistic, patient-centred, and effective EoLC. Four potential long-term outcomes were suggested: (1) increased use of anticipatory and regular end-of-life medications; (2) reduced end-of-life clinical and medication errors; (3) reduced unnecessary hospitalisations; (4) increased concordance between patient preferred and actual place of death. Key interventions focused on providing immediate information on what to do in such situations including: appraising the situation, developing an algorithm for a treatment plan (including whether or not to convey to hospital) and how to identify ongoing support in the community.

CONCLUSIONS

A Theory of Change approach was effective at identifying impact, outcomes, and the important features of an end-of-life intervention for paramedics. This study identified the need for paramedics to have immediate access to information and resources to support EoLC, which the workshop stakeholders are now seeking to develop as an intervention.

Inpatient hospice admissions. Who is admitted and why: a mixed-method prospective study

Background

Over the next two decades, the numbers of people who will need palliative care in the United Kingdom and Ireland is projected to increase. Hospices play a vital role supporting people who require specialist palliative care input through community-based and inpatient palliative care services. Evidence is needed to understand the role of these different services to inform future service development.

Objectives

To describe the reasons for admission, and outcomes at the end of the stay, for patients admitted to two hospice inpatient units (IPUs).

Design

This was a mixed-methods study using a convergent, parallel mixed-methods design.

Methods

We reviewed the case notes of all patients admitted to two hospice inpatient units from July to November 2019; conducted semi-structured interviews with patients and families; as well as brief structured interviews with inpatient unit staff.

Results

Two hundred fifty-nine patients were admitted to a hospice IPU, accounting for 276 admissions in total. Overall, 53% were female; median age was 71 years (range: 26-95 years). Most patients (95%) were White British or Scottish, and 95% had a cancer diagnosis. Most patients were admitted from the community, under one-third were admitted from hospital. Most (85%) had previous palliative care involvement. Nearly, half had district nurse support (48%). Worry and anxiety was frequently reported as a reason for admission, alongside physical concerns. Median length of stay was 12 days, and 68% died during their stay. Hospice was recorded as the preferred place of care for 56% of those who died there.

Conclusions

Sustained efforts to promote the hospice as place of care for people with conditions other than cancer are needed alongside greater clarity regarding of the role of the hospice IPU, and who would benefit most from IPU support.

Analysis of palliative care needs in hospitalized patients

AIM

To determine the prevalence of palliative care needs in patients in an acute care hospital and to analyze the profile of these patients.

DESIGN

We conducted a prospective cross-sectional study in an acute care hospital, in April 2018. The study population consisted of all patients over 18 years of age admitted to hospital wards and intensive care units. Variables were collected on a single day by six micro-teams using the NECPAL CCOMS-ICO© instrument. The descriptive analysis, on patient mortality and length of stay, was performed at a one-month follow-up.

RESULTS

We assessed 153 patients, of whom 65 (42.5%) were female, with a mean age of 68.17±17.03 years. A total of 45 patients (29.4%) were found to be SQ+, of which 42 were NECPAL+ (27.5%), with a mean age of 76.64±12.70 years. According to the disease indicators, 33.35% had cancer, 28.6% had heart disease, and 19% had COPD, resulting in a ratio of 1:3 between patients with cancer and non-cancer disease. Half of the inpatients in need of palliative care were in the Internal Medicine Unit.

CONCLUSIONS

Almost 28% of patients were identified as NECPAL+, most of them not identified as under palliative care in clinical records. Greater awareness and knowledge from healthcare professionals would facilitate the early identification of these patients and avoid overlooking palliative care needs.

The ideal and the real: Patient and bereaved family caregiver perspectives on the significance of place of death

Home has become established as the preferred place of death within health policy and practice in the UK and internationally. However, growing awareness of the structured inequalities underpinning end-of-life care and the challenges for family members undertaking care at home raise questions about the nature of patient and public preferences and priorities regarding place of death and the feasibility of home management of the complex care needs at the end-of-life. This paper presents findings from a qualitative study of 12 patients' and 34 bereaved family caregivers' perspectives and priorities regarding place of death. Participants expressed complex and nuanced accounts in which place of death was not afforded an overarching priority. The study findings point to public pragmatism and flexibility in relation to place of death, and the misalignment of current policy with public priorities that are predominantly for comfort and companionship at the end-of-life, regardless of place.

Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records

BACKGROUND

The accuracy of prognostication has important implications for patients, families, and health services since it may be linked to clinical decision-making, patient experience and outcomes and resource allocation. Study aim is to evaluate the accuracy of temporal predictions of survival in patients with cancer, dementia, heart, or respiratory disease.

METHODS

Accuracy of clinical prediction was evaluated using retrospective, observational cohort study of 98,187 individuals with a Coordinate My Care record, the Electronic Palliative Care Coordination System serving London, 2010-2020. The survival times of patients were summarised using median and interquartile ranges. Kaplan Meier survival curves were created to describe and compare survival across prognostic categories and disease trajectories. The extent of agreement between estimated and actual prognosis was quantified using linear weighted Kappa statistic.

RESULTS

Overall, 3% were predicted to live "days"; 13% "weeks"; 28% "months"; and 56% "year/years". The agreement between estimated and actual prognosis using linear weighted Kappa statistic was highest for patients with dementia/frailty (0.75) and cancer (0.73). Clinicians' estimates were able to discriminate (log-rank p < 0.001) between groups of patients with differing survival prospects. Across all disease groups, the accuracy of survival estimates was high for patients who were likely to live for fewer than 14 days (74% accuracy) or for more than one year (83% accuracy), but less accurate at predicting survival of "weeks" or "months" (32% accuracy).

CONCLUSION

Clinicians are good at identifying individuals who will die imminently and those who will live for much longer. The accuracy of prognostication for these time frames differs across major disease categories, but remains acceptable even in non-cancer patients, including patients with dementia. Advance Care Planning and timely access to palliative care based on individual patient needs may be beneficial for those where there is significant prognostic uncertainty; those who are neither imminently dying nor expected to live for "years".

Patterns of visiting nurse services for older adults in Japanese residential facilities: A latent class analysis

AIM

To examine the patterns of the visiting nurse services provided to older adults in a type of residential facility in Japan and to identify associated factors.

METHODS

This secondary analysis used past survey data from visiting nurse service agencies providing services to older adults in residential facilities with few nurses, known as non-specified facilities in Japan. Approximately 515 cases were used to determine the patterns of visiting nurse services using latent class analysis. Multinomial logistic regression analysis examined the relationships between identified classes, residents' characteristics, facilities, and services provided by visiting nurses.

RESULTS

Three service patterns were identified as follows: Class 1, observational and follow-up care (37.1%); Class 2, chronic disease care (35.7%); and Class 3, end-of-life care (27.2%). Class 1 comprised fewer nursing services than the other classes and primarily involved the observation of medical conditions, whereas Classes 2 and 3 involved higher care-need levels and provided diverse nursing care support. Specifically, Class 3 was associated with the inclusion of family (odds ratio: 2.42) and a visiting nurse at the attached facility (odds ratio: 4.88).

CONCLUSIONS

The three identified classes describe the older residents' healthcare needs. Additionally, the factors associated with the end-of-life care class suggest that older residents with these factors may have difficulty accessing end-of-life care by visiting nurses. Geriatr Gerontol Int 2023; ••: ••-••.

Provision of palliative and end-of-life care in UK care homes during the COVID-19 pandemic: A mixed methods observational study with implications for policy

Introduction

Little consideration has been given to how the provision of palliative and end-of-life care in care homes was affected by COVID-19. The aims of this study were to: (i) investigate the response of UK care homes in meeting the rapidly increasing need for palliative and end-of-life care during the COVID-19 pandemic and (ii) propose policy recommendations for strengthening the provision of palliative and end-of-life care within care homes.

Materials and methods

A mixed methods observational study was conducted, which incorporated (i) an online cross-sectional survey of UK care homes and (ii) qualitative interviews with care home practitioners. Participants for the survey were recruited between April and September 2021. Survey participants indicating availability to participate in an interview were recruited using a purposive sampling approach between June and October 2021. Data were integrated through analytic triangulation in which we sought areas of convergence, divergence, and complementarity.

Results

There were 107 responses to the survey and 27 interviews. We found that (i) relationship-centered care is crucial to high-quality palliative and end-of-life care within care homes, but this was disrupted during the pandemic. (ii) Care homes' ability to maintain high-quality relationship-centered care required key "pillars" being in place: integration with external healthcare systems, digital inclusion, and a supported workforce. Inequities within the care home sector meant that in some services these pillars were compromised, and relationship-centered care suffered. (iii) The provision of relationship-centered care was undermined by care home staff feeling that their efforts and expertise in delivering palliative and end-of-life care often went unrecognized/undervalued.

Conclusion

Relationship-centered care is a key component of high-quality palliative and end-of-life care in care homes, but this was disrupted during the COVID-19 pandemic. We identify key policy priorities to equip care homes with the resources, capacity, and expertise needed to deliver palliative and end-of-life care: (i) integration within health and social care systems, (ii) digital inclusivity, (iii) workforce development, (iv) support for care home managers, and (v) addressing (dis)parities of esteem. These policy recommendations inform, extend, and align with policies and initiatives within the UK and internationally.

Adults above 65 years of intention to use homecare hospice and a study on the factors influencing the perception of hospice·palliative care service

BACKGROUND

This study is a descriptive correlation survey conducted to understand the effect of attitudes toward death, hospice palliative care perception, and knowledge on homecare hospice use intention for adult men and women aged 65 or older ones.

AIM

This study identified factors affecting the intention to use homecare hospice and the perception of hospice·palliative care for adults aged 65 or older.

METHODS

Researchers used tools which were intention to use homecare hospice, the hospice palliative care knowledge, death orientation, hospice palliative perception.

RESULTS

The higher the perception of hospice·palliative care, for men than women, then they are the higher the willingness to use homecare hospice. In addition, the factors influencing the perception of hospice·palliative care of subjects who are willing to use homecare hospice were education and hospice·palliative care knowledge.

CONCLUSION

By improving hospice·palliative care perception by acquiring hospice·palliative care knowledge, people will choose the place where they want to die. In addition, once there is an increasing demand for it, nations and Institutions can help to set up support homecare hospice. For this, campaigns, and education to provide knowledge and improve perception of hospice·palliative care must be continued at the socio-cultural level.

How is community based 'out-of-hours' care provided to patients with advanced illness near the end of life: A systematic review of care provision

BACKGROUND

Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes.

AIM

To review systematically the components, outcomes and economic evaluation of community-based 'out-of-hours' care for patients near the end of life and their families.

DESIGN

Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting.

DATA SOURCES

Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022.

RESULTS

About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation.

CONCLUSIONS

The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.

Nursing Home Residents Hospitalization at the End of Life: Experience and Predictors in Portuguese Nursing Homes

(1) Background: Nursing Home (NH) residents are a population with health and social vulnerabilities, for whom emergency department visits or hospitalization near the end of life can be considered a marker of healthcare aggressiveness. With the present study, we intend to identify and characterize acute care transitions in the last year of life in Portuguese NH residents, to characterize care integration between the different care levels, and identify predictors of death at hospital and potentially burdensome transitions; (2) Methods: a retrospective after-death study was performed, covering 18 months prior to the emergence of the COVID-19 pandemic, in a nationwide sample of Portuguese NH with 614 residents; (3) Results: 176 deceased patients were included. More than half of NH residents died at hospital. One-third experienced a potentially burdensome care transition in the last 3 days of life, and 48.3% in the last 90 days. Younger age and higher technical staff support were associated with death at hospital and a higher likelihood of burdensome transitions in the last year of life, and Palliative Care team support with less. Advanced Care planning was almost absent; (4) Conclusions: The studied population was frail and old without advance directives in place, and subject to frequent hospitalization and potentially burdensome transitions near the end of life. Unlike other studies, staff provisioning did not improve the outcomes. The results may be related to a low social and professional awareness of Palliative Care and warrant further study.

A Situation-Specific Theory of End-of-Life Communication in Nursing Homes

High-quality end-of-life communication between healthcare professionals (HCPs), patients and/or their family caregivers (FCs) improves quality of life and reduces non-beneficial care at the end of life. Nursing homes (NHs) are among the contexts at the forefront of these conversations. Having a solid theoretical basis for the role of end-of-life communication in NHs in transitioning to palliative-oriented care can offer indications for research, practice, education, and policy related to geropalliative care. This study aimed to develop a situation-specific theory of end-of-life communication in NHs by refining an existing theory. A four-step integrative approach was employed that included: (1) checking the assumptions for theorization; (2) exploring the phenomenon through multiple sources; (3) theorizing; and (4) reporting. All elements of the existing end-of-life communication theory in NHs were confirmed: end-of-life communication improved the understanding of FCs about their relatives' health conditions, shared decision-making, and reflections on the desired preferences of residents/FCs for care at the end of life. Furthermore, the family environment affected the burden of FCs in the decision-making process. Finally, time and resource constraints, regulations, visitation restrictions due to the COVID-19 pandemic, and social and cultural values influenced the quality and timing of communication. The study findings confirmed the impact of the political, historical, social, and cultural context on end-of-life communication, thus providing the basis for a situation-specific theory.

Identifying the areas of low self-reported confidence of internal medicine residents in geriatrics: a descriptive study of findings from a structured geriatrics skills assessment survey

BACKGROUND

Currently, no standardized methods exist to assess the geriatric skills and training needs of internal medicine trainees to enable them to become confident in caring for older patients. This study aimed to describe the self-reported confidence and training requirements in core geriatric skills amongst internal medicine residents in Toronto, Ontario using a standardized assessment tool.

METHODS

This study used a novel self-rating instrument, known as the Geriatric Skills Assessment Tool (GSAT), among incoming and current internal medicine residents at the University of Toronto, to describe self-reported confidence in performing, teaching and interest in further training with regard to 15 core geriatric skills previously identified by the American Board of Internal Medicine.

RESULTS

190 (75.1%) out of 253 eligible incoming (Year 0) and current internal medicine residents (Years 1-3) completed the GSAT. Year 1-3 internal medicine residents who had completed a geriatric rotation reported being significantly more confident in performing 13/15 (P < 0.001 to P = 0.04) and in teaching 9/15 GSAT skills (P < 0.001 to P = 0.04). Overall, the residents surveyed identified their highest confidence in administering the Mini-Mental Status Examination and lowest confidence in assessing fall risk using a gait and balance tool, and in evaluating and managing chronic pain.

CONCLUSION

A structured needs assessment like the GSAT can be valuable in identifying the geriatric training needs of internal medicine trainees based on their reported levels of self-confidence. Residents in internal medicine could further benefit from completing a mandatory geriatric rotation early in their training, since this may improve their overall confidence in providing care for the mostly older patients they will work with during their residency and beyond.

End of life decisions and preference of place of death among geriatric and chronic disease patients: A scoping review

Background

Geriatric and chronic disease patients and families consider the nature, time, and place of death because issues related to the end of life are rarely discussed. This study assessed the end of life decisions and preferences among geriatric and chronic disease patients.

Methods

There was an in-depth search in five electronic databases (PubMed Central, CINAHL, Embase, Web of Science, and Scopus) using the population, concept, and context, framework. A matrix was developed, discussed, accepted, and used for data extraction. Convergent synthesis and thematic data analysis technique were adopted for the analysis. The reporting of findings was done in accordance with the JBI and PRISMA guidelines for reviews.

Results

From the data analysis, home-based end of life care was intuitive and included home visits, telephone follow-up, and patient-initiated services. The key themes that emerged from our analysis that sought to influence end end of life decisions were 1) approach to home-based end of life care, 2) patient and family characteristics, 3) clinical characteristics of the patient, 4) health care provider factors, 5) satisfaction and care rendered to the patient and family, 6) family preference of the place of death, 7) collaboration between multidisciplinary teams of care, and 8) challenges associated with the home-based end of life care. The personal characteristics of the nurse (age, personal and work experience, nursing perspective, and competence) and conducting a home visit influenced patient and family end of life decision. Multidisciplinary care teams (nurses and palliative care specialists) were important in delivering effective end-of-life services.

Conclusion

To support patients in making informed decisions, they must be educated on expected outcomes and implications, adverse impacts of decisions, and the emotional influence on the bereaved family. It is important that divergent technological methods are leveraged to provide essential care to patients nearing the end of life at home. Advancing the quality of end of life care techniques through home visiting will improve the feeling of patients and families about the dying process.

Tweetable abstracts

End-of-life preferences warrants that, divergent technological methods are leveraged to provide care to patients nearing the end of life.

The impact of Covid-19 pandemic on hospices: A systematic integrated review and synthesis of recommendations for policy and practice

Background

The Covid-19 pandemic resulted in the development of numerous recommendations for practice and policy for specialist palliative care provided by hospices in United Kingdom (UK), as hospices were significantly affected by the pandemic and protections put in place.The aim of this review is to identify and synthesise recommendations or implications for policy and practice that have been generated for adult hospice specialist palliative care during the first 24 months of the Covid-19 pandemic.

Methods

AMED, BNI, CINAHL, EMBASE, EMCARE, HMIC, Medline, PsycINFO, PubMed databases were searched for peer-reviewed papers, as well as hand searchers for grey literature. Literature relating to hospices and Covid-19 in the UK were included and a thematic synthesis of recommendations for hospice policy and practice was undertaken.

Results

858 articles were identified with 12 meeting the inclusion criteria. Fifty-eight recommendations or implications were identified: 31 for policy, 27 for practice, and 10 covering both. Recommendations were organised under ten themes. There were several recommendations seeking to secure hospice resources to mitigate the short-term impact of the pandemic, as well as those focused on longer-term implications such as core funding. The impact of the pandemic on the quality of hospice care was the focus for numerous recommendations around improving integration of hospice care in the community, provision of bereavement support and better use of Advance Care Plans (ACP). However, there were significant gaps related to carer visitation in hospices, inequities of palliative care, or hospice-at-home services.

Conclusion

The Covid-19 pandemic and protections exposed several ongoing policy and practice needs, especially around hospice resources, while generating novel issues for hospices to address. Significant policy gaps remain to be addressed to mitigate the impact of the pandemic on the quality of hospice specialist palliative care.

The Experiences of Informal Carers during the COVID-19 Pandemic: A Qualitative Systematic Review

OBJECTIVES

To identify, critically appraise and synthesise the qualitative literature on the experiences of informal carers of people with long-term conditions during the COVID-19 pandemic.

DESIGN

A qualitative systematic literature review.

DATA SOURCES

Eight electronic databases were systematically searched (Medline, Embase, CINAHL, PubMed, PsychINFO, Web of Science, Nursing and Allied Health and ASSIA) along with Google Scholar and handsearching via secondary sources.

STUDY SELECTION

Eligible studies had to include the experiences of informal carers (adults who are 65 or older), use a qualitative methodology and had to be written in English.

DATA EXTRACTION AND SYNTHESIS

Retrieved papers were quality assessed using the Critical Appraisal Skills Programme qualitative checklist and ranked for quality. Thematic analysis was used to synthesise the findings.

RESULTS

Fourteen studies were included, all from medical or nursing journals (n = 5 specifically gerontology). Four main themes were identified: (i) fear, (ii) uncertainty, (iii) burden and (iv) staying connected. Caregiving demands have increased for carers during the pandemic, as well as negative emotions such as fear and uncertainty. At the same time, less social support has been available, leading to concerns about carers' wellbeing and ability to cope.

CONCLUSION

Carers' needs have been exacerbated by the COVID-19 pandemic. Greater practical and emotional support is needed for carers from both formal services and community sources that considers their changing needs and offers educational and emotional support for long-term wellbeing. Strengths and Limitations: (1) This is the first systematic review to explore in depth the experiences of informal carers caring for people with a range of long-term conditions and from an international context. (2) The review includes an analysis of the quality of the studies, as well as a study of their relative contributions. (3) Further research is needed to explore the physical, emotional and financial impact of the pandemic for bereaved carers which is not captured in this review due to the lack of empirical data available at the time of review.

Charitably funded hospices and the challenges associated with the COVID-19 pandemic: a mixed-methods study (CovPall)

Background

Independent charitably funded hospices have been an important element of the UK healthcare response to the COVID-19 pandemic. Hospices usually have different funding streams, procurement processes, and governance arrangements compared to NHS provision, which may affect their experiences during the COVID-19 pandemic. The aim of this study is to understand the challenges faced by charitably funded hospices during the COVID-19 pandemic.

Methods

Eligible Organisations providing specialist palliative or hospice care completed the online CovPall survey (2020) which explored their response to the COVID-19 pandemic. Eligible organisations were then purposively selected to participate in interviews as part of qualitative case studies (2020-21) to understand challenges in more depth. Free-text responses from the survey were analysed using content analysis and were categorised accordingly. These categorisations were used a priori for a reflexive thematic analysis of interview data.

Results

143 UK independent charitably funded hospices completed the online CovPall survey. Five hospices subsequently participated in qualitative case studies (n = 24 staff interviews). Key themes include: vulnerabilities of funding; infection control during patient care; and bereavement support provision. Interviewees discussed the fragility of income due to fundraising events stopping; the difficulties of providing care to COVID-19 and non-COVID-19 patients within relatively small organisations; and challenges with maintaining the quality of bereavement services.

Conclusion

Some unique care and provision challenges during the COVID-19 pandemic were highlighted by charitably funded hospices. Funding core services charitably and independently may affect their ability to respond to pandemics, or scenarios where resources are unexpectedly insufficient.

Impact of the COVID-19 Pandemic on the Perceived Quality of Palliative Care in Nursing Homes

The Nursing Homes End-of-life Programme (NUHELP) was developed in 2017 and is based on quality standards of palliative care, but it was not implemented due to the outbreak of the COVID-19 pandemic.

OBJECTIVES

To describe perceptions among staff at nursing homes and primary health care (PHC) centres regarding the relevance, feasibility, and degree of achievement of quality standards for palliative care in nursing homes and to determine the differences in these perceptions before and after the pandemic.

METHODOLOGY

Cross-sectional descriptive study. Professionals at eight nursing homes and related PHC centres who participated in NUHELP development assessed 42 palliative care standards at two time points (2018 and 2022). The Mann-Whitney U test was applied to analyse differences in the scores between these two times and between perceptions at nursing homes and at PHC centres.

RESULTS

The study population consisted of 58 professionals in 2018 and 50 in 2022. The standard regarding communication with persons affected by the death of a family member was considered less relevant (p = 0.05), and that concerning the culturally sensitive and dignified treatment of the body was less fully achieved (p = 0.03) in 2022 than in 2018. Social support (p = 0.04), sharing information among the care team (p = 0.04), patient participation (p = 0.04) and information about the treatment provided (p = 0.03) were all more poorly achieved in 2022 than in 2018. The perceptions of nursing home and PHC workers differed in several respects.

CONCLUSIONS

Professional intercommunication and social support should be reinforced, and residents should be more actively involved in decision-making.

Implementation of an innovative model of community nursing for older adults based on Buurtzorg principles: a scoping review protocol

OBJECTIVE

The objective of this review is to map the international evidence on the implementation of the Buurtzorg model of community nursing practice for the care of older adults. We will describe where and how it has been used, and the challenges and facilitators of implementing this model of care.

INTRODUCTION

The challenges of aging have mobilized health systems around the world to replace the current facility- and disease-centered care model with integrated patient-centered care models. The Buurtzorg model provides autonomy to nurses, who, in turn, empower patients in need-based and self-reliant care.

INCLUSION CRITERIA

We will consider both published and unpublished studies and reports exploring the process of implementing the Buurtzorg community nursing model for the care of older adults (65 years and older) internationally, in all settings. Concepts of interest will include where the model has been used, how the model has been implemented, and what challenges and facilitators were reported.

METHODS

We will implement a three-step search strategy to locate both published and unpublished primary studies, theses, dissertations, book chapters, and text and opinion reports using the following databases: MEDLINE, LILACS, Cochrane CENTRAL, CINAHL, Web of Science, Google Scholar, Embase, Scopus, ProQuest Dissertations and Theses Global, and the official Buurtzorg website. We will present the search strategy in a PRISMA flow diagram. Data will be extracted using Excel spreadsheets and then analyzed narratively. Extracted data will be quantitatively pooled in tables using descriptive statistics to synthesize the characteristics of the reports and sample, followed by a qualitative summary of how the Buurtzorg model has been used, and the challenges and facilitators of implementing this care model.

'Mum, I think we might ring the ambulance, okay?' A qualitative exploration of bereaved family members' experiences of emergency ambulance care at the end of life

BACKGROUND

In the context of a sudden or unexpected event, people with a life-limiting illness and their family caregivers may be dependent on emergency ambulance services.

AIM

To explore bereaved family members' experiences of emergency ambulance care at the end of life.

DESIGN

A qualitative study using reflexive thematic analysis of data collected from semi-structured phone interviews.

SETTING/PARTICIPANTS

A purposive sample of 38 family caregivers identified from a database of deaths in Aotearoa, New Zealand.

RESULTS

Emergency ambulance personnel assist, inform and reassure patients and family caregivers managing distressing symptoms, falls, infections, unexpected events and death itself. Family members and patients are aware of the pressure on emergency services and sometimes hesitate to call an ambulance. Associating ambulances with unwanted transport to hospital is also a source of reluctance.

CONCLUSIONS

The generalist palliative care provided by emergency ambulance personnel is a vital service for patients in the last year of life, and their caregivers. This must be acknowledged in palliative care policy and supported with training, specialist consultation and adequate resources.

Factors associated with death places among elderly patients receiving home-based care

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care. This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors. The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37-7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12-25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03-0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03-0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13-0.90; P = .030). Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.

End-of-life and immediate postdeath acute hospital interventions: scoping review

BACKGROUND

Hospital remains the most common place of death in the UK, but there are ongoing concerns about the quality of end-of-life care provision in this setting. Evaluation of interventions in the last days of life or after a bereavement is methodologically and ethically challenging.

AIM

The aim was to describe interventions at the very end of life and in the immediate bereavement period in acute hospitals, with a particular focus on how these are evaluated.

METHOD

A scoping review was conducted. Studies were restricted to peer-reviewed original research or literature reviews, published between 2011 and 2021, and written in the English language. Databases searched were CINAHL, Medline and Psychinfo.

RESULTS

From the search findings, 42 studies were reviewed, including quantitative (n=7), qualitative (n=14), mixed method (n=4) and literature reviews (n=17). Much of the current research about hospital-based bereavement care is derived from the intensive and critical care settings. Three themes were identified: (1) person-centred/family-centred care (memorialisation), (2) institutional approaches (quality of the environment, leadership, system-wide approaches and culture), (3) infrastructure and support systems (transdisciplinary working and staff support). There were limited studies on interventions to support staff.

CONCLUSION

Currently, there are few comprehensive tools for evaluating complex service interventions in a way that provides meaningful transferable data. Quantitative studies do not capture the complexity inherent in this form of care. Further qualitative studies would offer important insights into the interventions.

Preferred Place of Death Discussions: Are They Informing and Empowering Patients and their Family Caregivers?

Factors influencing preferred place of death (PPoD) are variable between individuals. However, there is little understanding of how these preferences are formed and how consistent they are in the final months of life. In particular, the expectation and responsibility of family caregivers to provide unpaid caregiving support to their dying loved one in the home is often overlooked. There is a need for clinicians to take an individualised approach to PPoD conversations that is inclusive of the needs of both the patient and the family caregiver. More Good Deaths - A Change Programme responds to this gap in care by advancing the skills of clinicians having PPoD conversations with patients and their family caregivers. This paper describes the programme, providing insight into its benefits to advanced care planning and communication, as well as to our newest service - Cottage Hospice.

End of life care in UK care homes - controlled drugs: systematic review and narrative synthesis

BACKGROUND

Controlled drugs (CDs) such as opioids and midazolam are commonly used in end-of-life care symptom management for care home residents.

AIM

To review the published evidence concerning the prescribing, storage, use and disposal of CDs for end-of-life care for care home residents in the UK.

DESIGN

Systematic review and narrative synthesis.

METHODS

Seven databases (Medline, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Library, and Social Care Online) were searched from January 2000 to January 2021, alongside reference, citation and journal hand searches. Gough's 'Weight of Evidence' framework was used to appraise the relevance of studies to the review questions.

RESULTS

The search yielded 1279 titles, from which 125 abstracts and then 42 full-text papers were screened. 14 papers were included in the synthesis. Prescribing is primarily by general practitioners, with administration by nurses. Nurses frequently report feeling inadequately trained in the use of CDs. The storage, monitoring and disposal of end-of-life care CDs in UK care homes has not been researched to date. The attitudes and experiences of residents and family members regarding these medications also remain unknown.

CONCLUSION

The current widespread use of CDs for end-of-life care in care homes has a limited evidence base. The lack of research concerning the storing, monitoring and disposing of CDs, alongside the limited evidence concerning resident and family members' perspectives, is a significant knowledge deficit that requires urgent attention.

PROSPERO REGISTRATION NUMBER

CRD42020173014.