Hospitalization patterns and palliation in the last year of life among residents in long-term care

End-of-life care in U.S. nursing homes: a review of the evidence

OBJECTIVES

The purpose of this study was to systematically review the empiric evidence on end-of-life care in nursing homes in the United States The guiding research question for this review was what is the state of research evidence in end-of-life care in long-term care?

DESIGN

We conducted a systematic review of the literature.

DATA

The review was limited to published and indexed research in peer-reviewed journals in five major databases between 1995 and October 2002.

RESULTS

The initial search yielded a total of 395 articles. The search was narrowed, focusing on nursing homes in the United States and empiric research. The result was 43 articles related to research in end-of-life care in American nursing homes. It was categorized into eight foci: prognosis, pain, hospice, hospitalization, advanced care planning, communication, family perceptions, and miscellaneous.

CONCLUSION

There is a dearth of research published in end-of-life care in the nursing home setting. What is available is primarily descriptive. The empiric research only documents poor end-of-life care in U.S. nursing homes. Empiric evidence has grown in this area, but there is now a need for research of creative and innovative solutions aimed at improving the quality of end-of-life care in this setting.

Measuring End-of-Life Care Outcomes Prospectively

This paper discusses the state of the science in prospective measurement in end-of-life research and identifies particular areas for focused attention. Topics include defining the scope of inquiry, evaluating experiences of patients too ill to communicate, the role of proxy and family response, measurement sensitivity to change, the role of theory in guiding measurement efforts, evaluating relationships between domains of end-of-life experience, and measurement of cultural comprehensiveness. The state of the sciences calls for future research to (1) conduct longitudinal studies to capture transitions in end-of-life trajectories; (2) evaluate the quality of proxy reporting as it varies by rater relationship, domain, and over time; (3) use state-of-the art psychometric and longitudinal techniques to validate measures and to assess sensitivity to change; (4) develop further and test conceptual models of the experience of dying; (5) study the inter-relatedness of multiple dimensions of end-of-life trajectories; (6) compile updated information evaluating available measurement tools; and (7) conduct population- based research with attention to ethnic and age diversity.

End-of-life care in a nursing home: a study of family, nurse and healthcare aide perspectives

AIM

To examine the perspectives of family members, registered nurses and healthcare aides regarding the last 72 hours of Canadian nursing home residents' lives.

STUDY DESIGN

Exploratory, descriptive design using semistructured interviews.

SAMPLE

Consisted of 14 registered nurses and eight healthcare aides who had provided care within the last 72 hours before a resident's death and four family members who had visited within the same time frame.

SETTING

A 220-bed nursing home located within a larger long-term care facility in Canada.

METHODS

Thematic analysis was conducted independently and through consensus identified themes and subthemes emerging from the interviews.

FINDINGS

Dyspnea was a more common end-of-life (EoL) symptom for nursing home residents in this sample than was pain. Caring behaviours of staff were central to the resident's dying process and involved assessment, coordination of care, physical care, family education and nurture. Family members' ambivalence about the resident's death and fear of the resident dying alone were frequently noted.

CONCLUSIONS

Appropriate and timely symptom management and a range of caring behaviours of staff are critical elements in the dying experience of nursing home residents. Additional education and support for personnel involved with caring for this group will enhance end-of-life care.

Staff Perceptions Concerning Barriers and Facilitators to End-of-Life Care in the Nursing Home

Although many nursing home residents have chronic, life-limiting conditions, most die without the benefit of palliative care or with palliation delayed until the last days of life. The goal of this study was to determine whether the presence of a comprehensive palliative care program in nursing homes would affect the knowledge and attitudes of the staff. The intervention group was able to identify more problems in delivering palliative care than the control group, but this only reached statistical significance on 2 items. Nevertheless, the current study suggests that the presence of a palliative care program within a nursing home does increase general knowledge of the problems faced in caring for the dying.

Clinical indicators of treatment futility and imminent terminal decline as discussed by multidisciplinary teams in long-term care

Focus group methodology was used to describe how members of multidisciplinary teams in long-term care facilities recognize when residents are approaching end-stage disease, document evidence that associated treatment futility has occurred, and convey this information to the residents, each other, and family members. In addition to the typical clinical indicators of treatment futility found in the literature (e.g., recurrent infections, weight loss, falls, functional decline), team members described a set of physical and affective changes that were apparent to them as their residents approached trajectories of imminent terminal decline. While more difficult to quantify and measure, these other indicators have a significant impact on the ways that team members assess and interpret a person's survival potential. Using these indicators of both treatment failure and imminent decline requires knowledge of a resident's history, clinical condition, course of care, and individual idiosyncrasies. Together, the indicators offer important cues that are needed for the identification of persons who might benefit from earlier transitions to palliative care.

Managing family centered palliative care in aged and acute settings

This paper reports on the management of family centered palliative care in different aged care and acute Australian inpatient settings, following the integration of palliative care with mainstream services. Eighty-eight semistructured interviews were conducted and 425 questionnaires (Palliative Care Practices Questionnaire--PCPQ) were returned, completed from 12 regional and metropolitan locations. Transcribed interviews were analyzed using QSR NVivo and mean PCPQ scores from the four settings were compared. Scores on items from the PCPQ related to family centered care confirmed the analyses. Interviews revealed that factors contributing to the level of support for families offered in the various settings included the core business of the unit; the length of stay of the patients or residents; the acuity or symptom burden; and the coordinated involvement of the multidisciplinary team. Strategies for improving supportive family care are proposed.

Nursing home social worker skills and end-of-life planning

Little empirical information exists on nursing home social worker's involvement in advance care planning and end-of-life decision- making with nursing home residents and their family members. The purpose of this exploratory study was twofold: (1) to identify the frequency of skills associated with advance care planning that social workers use, and (2) to explore the factor structure of the scale used in the study. Results from 138 nursing home social worker respondents from New York State showed high frequency of advance directive discussions, care planning, and conflict resolution with families. The instrument factors clustered around administrative duties, and grief issues. There was substantial interest in continuing education in grief counseling with families.

Hospice and palliative care in nursing homes

This article reviews the challenges inherent in providing high-quality palliative care to dying nursing home residents and summarizes the efforts to address these challenges. It is suggested that a stronger physician presence and oversight of physicians knowledgeable in palliative care in nursing homes are needed to improve the quality of end-of-life care in nursing homes.

Palliative care units in The Netherlands: changes in patients' functional status and symptoms

Although efforts have been made to define optimal terminal care in palliative care units (PCUs), comprehensive longitudinal evaluations of care outcomes in PCUs at the end of life are scarce. In this study, changes in functional status (assistance needed for walking, and toilet use) and symptoms (pain, nausea, shortness of breath, depression, and anxiety) were assessed in all patients (n=355) admitted to 10 PCUs in Dutch nursing homes. Outcomes were measured at 24 hours, 48 hours, one week, and two weeks before death, and at PCU admission. Results show that functional status deteriorated from admission to one week before death, but most symptoms did not worsen in the last three weeks before death. Decreases in pain, anxiety, and nausea were observed. The results suggest that the care provided in the PCUs stabilized the symptom levels. Patients who die between two and four weeks appeared to have more favorable symptom change patterns than patients who die within two weeks, which supports the recommendation to admit eligible patients in earlier phases of their disease. Limitations include the use of proxy measures and some forms of selection bias, which may lead to underestimation of symptom levels.

Too Old to Care?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH (http://www.theschwarzcenter.org/rounds.asp). The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Ageism is a pervasive problem throughout society. It is rooted in language, attitudes, beliefs, behaviors, and policies. Aging profoundly influences physiology, challenging the medical community to accommodate but not discriminate. The elderly are at an increased risk of disease and disability. Sixty percent of cancer occurs in people aged 65 and older, and the population is aging. The treatment of cancer in the elderly is complicated by comorbidities and other physiological factors, particularly renal, bone marrow, and metabolic reserve. Caregivers have to treat patients in a manner that optimizes treatment and avoids anticipated harm. However, the caregiver is often faced with situations where they must balance their personal beliefs, professional values, and knowledge of medicine with their patients' preferences and needs. Discussion in the Rounds focused on age bias, drug toxicity, life prolongation, and symptom relief, with the role of the caregiver, and the relationship to the patient, being pivotal.

Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.

Lower respiratory infections in nursing home residents with dementia: a tale of two countries

PURPOSE

A focus on palliative care for residents with dementia is much more common in Dutch nursing homes than in the United States. We compared treatment and mortality in U.S. and Dutch nursing home residents with lower respiratory infections (LRI), which are often the immediate cause of death in dementia.

DESIGN AND METHODS

We studied two prospective cohorts--a study of pneumonia (n = 706) conducted in 61 psychogeriatric nursing homes throughout the Netherlands and 701 subjects with likely dementia from a study of LRIs in 36 nursing homes in Missouri.

RESULTS

Nursing home residents with dementia were more often treated without antibiotics in the Netherlands (23%) than in Missouri (15%). Indicators of severe illness operate in opposite directions: more severe illness is associated with antibiotic treatment in the United States, but with palliative treatment without antibiotics in the Netherlands.

IMPLICATIONS

Our findings are consistent with others in indicating problems with transition to palliative care for U.S. nursing home residents with dementia.

The use of advance directives in a population of Asian Indian Hindus

Advance directives are a way to communicate the kind of care that people desire at the end of life. Recent research shows that ethnic minorities have been found to complete advance directives significantly less often than Caucasians, and no information was available regarding advance directives in the Asian Indian population. To address this shortcoming, this descriptive exploratory design sampled a community sample of 45 Asian Indian Hindus. Being female and having an individualistic decision-making style were significantly positively correlated with advance directive completion. Having strong religious affiliation and a family decision-making style were significantly negatively correlated with advance directive completion. The results of this study provide needed information regarding the Asian Indian population and how Hinduism affects advance directives.

A profile of residents admitted to long-term care facilities for end-of-life care

INTRODUCTION

Permanent placement in a Long-Term-Care (LTC) facility following hospitalization or when staying at home is no longer a viable option is the reality for a growing number of Americans. When death is imminent, the specialized knowledge and skill of the hospice team is required and accepted as an important component of end-of-life (EOL) care. The provision of appropriate care at the EOL is contingent on accurate identification of those residents who are approaching the final stage of life. This study describes the prevalence, profile, and survivorship of residents admitted to LTC facilities, using the Minimum Data Set (MDS) designation of being at the EOL.

METHODS

A descriptive, correlational, retrospective cohort design was used to analyze all residents admitted to certified LTC facilities with hospice contracts in Missouri in 1999. Variables for analysis were selected from the MDS items that are clinically relevant for those residents at the EOL, for example, pain, incontinence, skin condition, activities of daily living (ADLs), depression, and weight loss. In addition, items regarding advance directives, use of special treatments, and diagnoses were selected because they are important to the care of residents at the EOL.

RESULTS

Of 492 eligible facilities, 159 were confirmed as providing hospice care. Of 9615 admissions to these facilities, 432 (4.5%) met the EOL care definition; half of these were receiving specialist hospice care. The EOL residents were distinguishable in terms of symptoms. Median survival time for EOL admissions was 33 days. At 6 months, only 17% of EOL admissions remained in the facility.

CONCLUSIONS

Residents designated as EOL who are admitted to LTC are a distinct group from other new residents, with identifiable needs requiring specialist attention. Accurate recognition that EOL is imminent is required for the development of appropriate strategies and resources for care.

End-of-life treatment preferences among older adults: a nurse practitioner initiated intervention

PURPOSE

To explore end-of-life treatment preferences (ELTP) among older adults and to test the impact of a nurse practitioner (NP) initiated intervention to facilitate the completion of ELTPs.

DATA SOURCES

A descriptive study including 135 older adults living in a continuing care retirement community.

CONCLUSIONS

The findings in this study suggest that the majority of older adults do not want life sustaining interventions at the end of life, but are willing to accept interventions that will keep them comfortable. ELTP can, however, change over time. An NP-initiated teaching intervention about advance directives and ELTP significantly increased the number of individuals who completed advance directive forms.

IMPLICATIONS FOR PRACTICE

With the advancement of medical technology, various life-sustaining treatments are available at the end of life. Older adults should be encouraged to establish their ELTPs while they are physically and mentally able to do so. Health care providers should initiate discussions about ELTP at regular intervals (yearly) to assist older adults in participating in decisions about their end-of-life care.

What impact do setting and transitions have on the quality of life at the end of life and the quality of the dying process?

PURPOSE

The aim of this article was to identify major research needs related to quality of life at the end of life and quality of the dying process for vulnerable older people at home, in assisted living facilities, in skilled nursing facilities, and in prisons.

DESIGN AND METHODS

Review and analysis of the literature was used.

RESULTS

The science is generally weak in relationship to what is known about quality of life at the end of life and quality of dying for vulnerable older adults in different settings. Few studies address actively dying patients and the reasons for transfers between home and other settings. Existing studies are primarily anecdotal, descriptive, have small samples, and involve a single setting. Participant decisional capacity is a barrier to conducting research in these settings.

IMPLICATIONS

Research recommendations for each setting and across settings are provided. The National Institutes of Health should clarify criteria for enrollment of persons with diminished, fluctuating, and absent decisional capacity in research.

Research design in end-of-life research: state of science

PURPOSE

The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research.

DESIGN AND METHODS

A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review.

RESULTS

Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death.

IMPLICATIONS

Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.

Older persons' ethical problems involving their health

Although older persons (aged 65 years and older) experience stressful ethical problems involving their health, research is lacking about this phenomenon. The purpose of this study was to describe and examine the content and basic nature of older persons' ethical problems concerning their health. The conceptual framework and method combined ethical enquiry and phenomenology. The participants were 18 older persons and 12 of their children or grandchildren (for contextual understanding). The 19 women and 11 men, 73% of whom were Caucasian, described 184 ethical problems, from which emerged 10 content categories. The basic nature of the ethical problems consisted of conflict, resolution and rationale. The results could assist health professionals to promote older persons' ethical decision making, quality of life, and good death.

Obstacles to palliation and end-of-life care in a long-term care facility

PURPOSE

This exploratory study used a set of four obstacle constructs derived from both the existing literature and our earlier work to describe the diverse end-of-life scenarios observed for a group of residents in a long-term care facility.

DESIGN AND METHODS

Data from a retrospective chart review and both quantitative and qualitative methods of data collection and analysis were used to examine in-depth the end-of-life experiences of all nursing home residents (N = 41) who died on the nursing care unit of a large continuing care retirement community during an 18-month period.

RESULTS

A hierarchy of obstacles to palliation and end-of-life care seems to exist in long-term care settings that begins with the lack of recognition that restorative, rehabilitative, or curative treatment futility has commenced. The next three obstacles in sequence include lack of communication among decision makers, no agreement on a course of care, and failure to implement a timely plan of care.

IMPLICATIONS

The findings highlight the importance of determining treatment futility as an initial step in the successful delivery of palliative and end-of-life care to residents in long-term care followed by the need for a deliberate and proactive series of actions and care planning processes.