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Bolt S, van der Steen J, Schols J, Zwakhalen S, Meijers J. What do relatives value most in end-of-life care for people with dementia? Int J Palliat Nurs 2019; 25:432-442. [DOI: 10.12968/ijpn.2019.25.9.432] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background:End-of-life care for older people with dementia is often sub-optimal. Understanding the experiences of the relatives involved in the care of the person with dementia may help to improve care practice.Aims:To investigate relatives' experiences with end-of-life care for people with dementia, comparing the nursing home and home setting.Methods:In-depth interviews were conducted with 32 individuals who were bereaved of someone with dementia. Thematic analysis was performed to identify main themes from the data.Findings:Experiences translated into four themes: acknowledging human dignity; being recognised as an important caregiver; (not) talking about death and dying and making decisions together. A lack of person-centered care was mainly evident in nursing homes. Relatives took on a more prominent role in the care of the older person with dementia when the relative was cared for in a home setting and this involvement in the care of the older person was something that the relatives valued. Surrogate decision-making induced similar challenges in both settings.Conclusion:It is important that healthcare professionals inform and support relatives to help them make decision about end-of-life care and preferences. Nursing homes should learn to offer the same standard of person-centred care as a home care setting, and ensure that relatives are still involved in the care of the person with dementia.
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Affiliation(s)
- Sascha Bolt
- PhD candidate, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Jenny van der Steen
- Associate Professor, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands, Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - Jos Schols
- Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Sandra Zwakhalen
- Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands
| | - Judith Meijers
- Assistant Professor, Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Lifesciences, Maastricht University, Maastricht, the Netherlands, Zuyderland Care, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
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102
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Giger M, Voneschen N, Brunkert T, Zúñiga F. Care workers' view on factors leading to unplanned hospitalizations of nursing home residents: A cross-sectional multicenter study. Geriatr Nurs 2019; 41:110-117. [PMID: 31447139 DOI: 10.1016/j.gerinurse.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/10/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022]
Abstract
Nursing home residents have a high risk of adverse events during hospitalizations. Since up to two-thirds of hospitalizations of nursing home residents are rated as potentially preventable, this study aimed to describe factors related to unplanned hospitalizations and to describe rates of unplanned hospitalizations, comparing differences between high- and low-hospitalization nursing homes. This cross-sectional multicenter study was conducted in 19 Swiss nursing homes and used questionnaire surveys of ward supervisors (n = 33) and nursing staff (n = 146) and retrospectively assessed hospitalization data. The study revealed several issues regarding unplanned hospitalizations, mostly concerning limitations regarding physicians' availability, lack of acquaintance of on-call physicians with the residents, and health professionals' lack of knowledge about the residents' wishes concerning therapeutic decisions. Our findings suggest that standardizing advance care planning processes and better physician availability might further reduce hospitalizations and improve quality of care in nursing homes.
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Affiliation(s)
- Max Giger
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
| | - Nina Voneschen
- Alterszentrum Wiesendamm, Wiesendamm 20, Basel 4057, Switzerland.
| | - Thekla Brunkert
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
| | - Franziska Zúñiga
- Nursing Science (INS), Department Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel 4056, Switzerland.
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103
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Bally KW, Krones T, Jox RJ. Advance Care Planning for People with Dementia: The Role of General Practitioners. Gerontology 2019; 66:40-46. [PMID: 31212289 DOI: 10.1159/000500809] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/07/2019] [Indexed: 11/19/2022] Open
Abstract
General practitioners (GPs) play a key role in the timely diagnosis of dementia and also in advance care planning (ACP). They often have known patients and their families for decades and are familiar with their values and treatment preferences; they are, therefore, in a position to initiate the ACP process even before the appearance of the first symptoms of dementia and certainly following disclosure of the diagnosis. To do so, they should recognise whether patients are receptive to an ACP consultation or whether they might reject it for personal, social or cultural reasons. Under no circumstances should the patient or their family be coerced into making these provisions. In most countries, the current framework does not provide enough time and money for GPs to carry out actual ACP consultations completely on their own. There is evidence that specially trained health professionals are able to more effectively discuss treatment goals and limits of life-prolonging measures than GPs who are well acquainted with their patients. Consequently, we suggest that it will be the GPs' task to seize the right moment for starting an ACP process, to raise awareness of patients and their relatives about ACP, to test the patient's decision-making capacity and, finally, to involve appropriately trained healthcare professionals in the actual ACP consultation process. Care should be taken that these professionals delivering time-intensive ACP consultations are not only able to reflect on the patient's values but are also familiar with the course of the disease, the expected complications and the decisions that can be anticipated. The GP will ensure an active exchange with the ACP professional and should have access to the documentation drawn up in the ACP consultation process (treatment plan and advance directive including instructions for medical emergencies) as soon as possible. GPs as coordinators of healthcare provision should document appropriately all specialists involved in the care and ensure that treatment decisions are implemented in accordance with the patient's preferences for future care or the presumed will of the patient.
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Affiliation(s)
- Klaus W Bally
- Centre for Primary Health Care, University of Basel, Basel, Switzerland,
| | - Tanja Krones
- Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zürich, Switzerland
| | - Ralf J Jox
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Institute of Humanities in Medicine, Lausanne University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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104
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Sævareid TJL, Førde R, Thoresen L, Lillemoen L, Pedersen R. Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers. Clin Interv Aging 2019; 14:997-1005. [PMID: 31213786 PMCID: PMC6549780 DOI: 10.2147/cia.s203298] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/23/2023] Open
Abstract
Purpose: Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance. Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP. Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources. Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.
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Affiliation(s)
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Health Sciences, University of Oslo, Oslo, Norway
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105
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Cotter VT, Hasan MM, Ahn J, Budhathoki C, Oh E. A Practice Improvement Project to Increase Advance Care Planning in a Dementia Specialty Practice. Am J Hosp Palliat Care 2019; 36:831-835. [DOI: 10.1177/1049909119841544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP ( P = .033), belief that ACP improves outcomes in dementia ( P = .035), knowledge about ACP Medicare billing codes and requirements ( P = .002), and belief that they have support from other personnel to implement ACP ( P = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% ( P = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% ( P = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% ( P = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.
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Affiliation(s)
| | | | - Jheesoo Ahn
- Johns Hopkins School of Nursing, Baltimore, MD, USA
| | | | - Esther Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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106
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Affiliation(s)
- Lieve Van den Block
- Professor of Aging and Palliative Care Research, VUB-UGhent End-of-Care Research Group, Department of Family Medicine and Chronic Care and Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Ixelles, Belgium
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107
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Harrison Dening K, Sampson EL, De Vries K. Advance care planning in dementia: recommendations for healthcare professionals. Palliat Care 2019; 12:1178224219826579. [PMID: 30833812 PMCID: PMC6393818 DOI: 10.1177/1178224219826579] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/17/2022] Open
Abstract
The process of advance care planning in dementia is far from straightforward; as dementia progresses, the ability to consider future thoughts and actions becomes compromised, thus affecting decision-making abilities. Family carers find themselves increasingly in a position where they need to inform, or directly make, decisions on behalf of the person with dementia. This article discusses the context and importance of a palliative care approach and recommends rationales and strategies for healthcare professionals to support families affected by dementia to better plan for their future care.
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Affiliation(s)
- Karen Harrison Dening
- Research & Publications, Dementia UK, London, UK; School of Nursing and Midwifery, De Montfort University, Leicester, UK
| | - Elizabeth L Sampson
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kay De Vries
- School of Nursing and Midwifery, De Montfort University, Leicester, UK
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108
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Evenblij K, Ten Koppel M, Smets T, Widdershoven GAM, Onwuteaka-Philipsen BD, Pasman HRW. Are care staff equipped for end-of-life communication? A cross-sectional study in long-term care facilities to identify determinants of self-efficacy. BMC Palliat Care 2019; 18:1. [PMID: 30621703 PMCID: PMC6323808 DOI: 10.1186/s12904-018-0388-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background End-of-life conversations are rarely initiated by care staff in long-term care facilities. A possible explanation is care staff’s lack of self-efficacy in such conversations. Research into the determinants of self-efficacy for nurses and care assistants in end-of-life communication is scarce and self-efficacy might differ between care staff of mental health facilities, nursing homes, and care homes. This study aimed to explore differences between care staff in mental health facilities, nursing homes, and care homes with regard to knowledge about palliative care, time pressure, and self-efficacy in end-of-life communication, as well as aiming to identify determinants of high self-efficacy in end-of-life communication. Methods Two cross-sectional Dutch studies, one in mental health facilities and one in nursing and care homes (PACE study). Nurses and care assistants were invited to complete a questionnaire in 2015. Multivariable logistic regression analyses were performed to identify determinants of high self-efficacy. Results Five hundred forty one nurses and care assistants completed a survey; 137 worked in mental health facilities, 172 in nursing homes, and 232 in care homes. Care staff at mental health facilities were the most knowledgeable about the World Health Organization’s definition of palliative care: 76% answered 4–5 out of 5 items correctly compared to 38% of nursing home staff and 40% of care home staff (p < 0.001). Around 60% of care staff in all settings experienced time pressure. Care staff had high self-efficacy regarding end-of-life communication with patients: the overall mean score across all facilities was 5.47 out of 7 (standard deviation 1.25). Determinants of high self-efficacy were working in a mental health facility, age > 36, female, with formal palliative care training, and knowledge of the palliative care definition. Conclusion Mental healthcare staff knew more about palliative care and had higher self-efficacy in end-of-life communication compared to nursing and care home staff. Educating care staff about providing palliative care and training them in it might improve end-of-life communication in these facilities.
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Affiliation(s)
- Kirsten Evenblij
- Amsterdam UMC, Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands.
| | - Maud Ten Koppel
- Amsterdam UMC, Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium
| | - Guy A M Widdershoven
- Amsterdam UMC, Department of Medical Humanities, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Amsterdam UMC, Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007, Amsterdam, MB, Netherlands
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109
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Shelton W, Tenenbaum E, Costello K, Hoffman D. Empowering Patients with Alzheimer's Disease To Avoid Unwanted Medical Care: A Look At The Dementia Care Triad. Am J Alzheimers Dis Other Demen 2018; 34:1533317518817614. [PMID: 30541327 PMCID: PMC10852523 DOI: 10.1177/1533317518817614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with Alzheimer's disease and other types of dementia with acute medical problems, who have lost capacity and are without advance directives, are at risk of being over treated inhospitals. To deal with this growing demographic and ethical crisis, patients with dementia need to plan for their future medical care while they have capacity to do so. This article will examine the role of each member of the dementia care triad and how to empower the patient to participate in planning future medical care. A case will be made that physicians have the same professional disclosure obligations to dementia patients as they do to all other capable patients with terminal illnesses. Because there is little consensus about what facts should be included in a diagnostic disclosure, this article will offer a proposal to empower newly diagnosed patients with dementia with capacity to plan for their future medical care.
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Affiliation(s)
- Wayne Shelton
- Alden March Bioethics Institute, Albany Medical College, Albany, NY, USA
| | - Evelyn Tenenbaum
- Albany Law School, Alden March Bioethics Institute, Albany, NY, USA
| | - Kevin Costello
- Department of Medicine, Albany Medical College, Albany, NY, USA
| | - David Hoffman
- New York State Department of Health, Albany, NY, USA
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