1
|
Ludwick R, Baughman KR. Education, Policy, and Advocacy in Predicting Use of Do-Not-Hospitalize Orders in Skilled Nursing Facilities. J Gerontol Nurs 2022; 48:45-52. [PMID: 36286504 DOI: 10.3928/00989134-20221003-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Nurses and social workers are uniquely positioned to advocate for patients' wishes for do-not-hospitalize (DNH) directives. The purpose of the current study was to explore the impact of DNH education, policy, and advocacy on the use of DNH orders by nurses (RNs and licensed practical nurses [LPNs]) and social workers employed in skilled nursing facilities (SNFs). This multisite secondary analysis used cross-sectional survey data and analyzed responses of RNs, LPNs, and social workers (N = 354) from 29 urban SNFs. Mixed model regression was used to examine possible predictors of frequency of DNH orders within SNFs while adjusting for random effects. Results showed that having a DNH written policy, education on DNH orders, and having an advanced care planning advocate in the facility were strongly associated with a higher reported frequency of DNH discussions with residents and their families (p < 0.01 for each variable). [Journal of Gerontological Nursing, 48(11), 45-52.].
Collapse
|
2
|
Vellani S, Green E, Kulasegaram P, Sussman T, Wickson-Griffiths A, Kaasalainen S. Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study. BMC Palliat Care 2022; 21:127. [PMID: 35836164 PMCID: PMC9284816 DOI: 10.1186/s12904-022-01014-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background Residents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process. Objectives The aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs. Methods This study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada. Findings There were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs. Discussion The findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care. Conclusion The findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01014-2.
Collapse
Affiliation(s)
- Shirin Vellani
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 3Z1, Canada
| | - Elizabeth Green
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 3Z1, Canada
| | - Pereya Kulasegaram
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 3Z1, Canada
| | - Tamara Sussman
- Faculty of Arts, School of Social Work, McGill University, 3506 University St, Montreal, QC, H3A 2A7, Canada
| | - Abby Wickson-Griffiths
- Faculty of Nursing, University of Regina, 3737 Wascana Parkway, Regina, SK, S4S0A2, Canada
| | - Sharon Kaasalainen
- Faculty of Health Sciences, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 3Z1, Canada.
| |
Collapse
|
3
|
Gaugler JE, Mitchell LL. Reimagining Family Involvement in Residential Long-Term Care. J Am Med Dir Assoc 2022; 23:235-240. [PMID: 34973167 PMCID: PMC8821144 DOI: 10.1016/j.jamda.2021.12.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
Although descriptions of family involvement in residential long-term care (RLTC) are available in the scientific literature, how family involvement is optimized in nursing homes or assisted living settings remains underexplored. During the facility lockdowns and visitor restrictions of the COVID-19 pandemic, residents experienced social deprivation that may have resulted in significant and adverse health outcomes. As with so many other critical issues in RLTC, the COVID-19 pandemic has magnified the need to determine how families can remain most effectively involved in the lives of residents. This article seeks to better understand the state of the science of family involvement in RTLC and how the COVID-19 pandemic has expedited the need to revisit, and reimagine, family involvement in RLTC.
Collapse
Affiliation(s)
- Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | | |
Collapse
|
4
|
Abken ES, Perkins MM, Bender AA. Assisted Living Administrators' Approaches to Advance Care Planning. J Appl Gerontol 2022; 41:391-400. [PMID: 33504248 PMCID: PMC8313630 DOI: 10.1177/0733464820988803] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This project examined administrator processes, barriers, and facilitators for conducting advance care planning in assisted living. METHOD Data from qualitative interviews with 27 administrators from seven diverse assisted living communities in the metropolitan Atlanta area were linked with descriptive and administrative data collected from each site and analyzed using thematic analysis. RESULTS Although administrators generally contended with a lack of staff training and stakeholders' reluctance to discuss advance care planning and end-of-life care, important facilitators of advance care planning in some assisted living communities included periodic follow-up discussions of residents' wishes and successfully educating consumers about the importance of planning. Three study communities whose administrators discussed planning with residents and informal caregivers during regular care plan meetings had more advance care planning documents on file. DISCUSSION These findings demonstrate the potential for nonmedical organizations, such as assisted living, to successfully promote advance care planning among their members.
Collapse
Affiliation(s)
| | - Molly M. Perkins
- Emory University
- Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center
| | | |
Collapse
|
5
|
Factors associated with surrogate families’ life-sustaining treatment preferences for patients at home or in a geriatric health service facility: A cross-sectional study. Palliat Support Care 2021; 20:334-341. [DOI: 10.1017/s1478951521001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Recently, end-of-life preference in palliative care has been gaining attention in Japan. The Ministry of Health, Labor, and Welfare established the Japanese basic policy in November 2018. Patients’ decision-making is recommended; however, patients with dementia or other disorders cannot make such decisions by themselves. Thus, healthcare providers may contact surrogates and consider their backgrounds for better decision-making. Hence, the preferences of home caregivers’ and geriatric health service facility (GHSF) residents’ families on patient life-sustaining treatment (LST) were investigated.
Method
This cross-sectional study involved home caregivers’ and GHSF residents’ families in Japan. We distributed 925 self-reported questionnaires comprising items, such as the number of people living together, care duration, comprehension of doctor's explanations, the Patient Health Questionnaire (PHQ)-9 and Short Form (SF)-8, and families’ LST preference for patients.
Results
In all, 619 valid responses were obtained [242 men and 377 women (309 in the HOME Caregivers Group, response rate = 61.1%; 310 in the GHSF Group, response rate = 74.0%)]. LST preference was significantly associated with sex, the number of people living together, care duration, and comprehension of doctors’ explanations in the HOME Caregivers Group but was not significantly associated with the GHSF Group. Furthermore, PHQ-9/SF-8 scores were not significantly associated with LST preference.
Significance of results
There were many differences in opinions about LST preference between home caregivers’ and GHSF residents’ families. The results suggested that the burden of nursing care was greater and harder in home caregiver families, and these factors may be related to the LST preference for a patient.
Collapse
|
6
|
Gilissen J, Pivodic L, Wendrich-van Dael A, Gastmans C, Vander Stichele R, Van Humbeeck L, Deliens L, Van den Block L. Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program. PLoS One 2019; 14:e0223586. [PMID: 31622389 PMCID: PMC6797173 DOI: 10.1371/journal.pone.0223586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 09/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice. OBJECTIVES We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner. DESIGN To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling. SETTING AND PARTICIPANTS Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer. METHODS The work was carried out by means of 1) operationalization of key intervention components-identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes-into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis. RESULTS The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning. CONCLUSIONS The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.
Collapse
Affiliation(s)
- Joni Gilissen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Lara Pivodic
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | | | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven (KUL), Brussels, Belgium
| | | | | | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Lieve Van den Block
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Family Medicine and Chronic Care, and Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| |
Collapse
|
7
|
Hagiwara S, Kaneko M, Aoki M, Murata M, Ichikawa Y, Nakajima J, Isshiki Y, Sawada Y, Tamura J, Oshima K. Can the Wish to Receive Intensive Treatment in Elderly Patients with Respiratory Tract Infection Be Predicted? Intern Med 2018; 57. [PMID: 29526934 PMCID: PMC6096014 DOI: 10.2169/internalmedicine.0155-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Almost no Japanese elderly patients have an advance directive (AD). Our aim was to determine whether or not the wish to receive intensive care in elderly patients with respiratory tract infection could be predicted from the prehospital data. Methods In this retrospective study, we reviewed patients ≥65 years of age with respiratory tract infection who had been transferred to our hospital by ambulance between September 2014 and August 2016. The patients were divided into two groups according to whether or not they wished to receive intensive treatment. We placed patients without a wish to receive intensive treatments (WITs) in Group A and patients with a WITs in Group B. We then analyzed parameters that could be determined in the prehospital phase and compared the findings between the groups. Results Thirty-seven patients were in Group A, and 67 patients were in Group B. None of the patients in this study had an AD. There were significant differences in the age, rate of residence in an extended care facility, frequency of inability to care for oneself fully, frequency of dementia, number of prescribed drugs, and Glasgow coma scale (GCS) on a univariate analysis. A logistic regression analysis showed that the inability to care for oneself fully [odds ratio (OR): 4.521, 95% confidence interval (CI): 2.024-10.096, p<0.001] and a low GCS (OR 0.885, 95%CI 0.838-0.935, p<0.001) were related to a WITs. Conclusion Elderly patients who are unable to care for themselves and who have a low GCS in the prehospital stage are likely not to want intensive treatment.
Collapse
Affiliation(s)
- Shuichi Hagiwara
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Minoru Kaneko
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Masato Murata
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Yumi Ichikawa
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Jun Nakajima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Yuta Isshiki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| | - Jun'ichi Tamura
- Emergency Medical Care Center, Gunma University Hospital, Japan
- Department of General Medicine, Gunma University Graduate School of Medicine, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Japan
- Emergency Medical Care Center, Gunma University Hospital, Japan
| |
Collapse
|
8
|
Bartley MM, Quigg SM, Chandra A, Takahashi PY. Health Outcomes From Assisted Living Facilities: A Cohort Study of a Primary Care Practice. J Am Med Dir Assoc 2018; 19. [PMID: 32774179 DOI: 10.1016/j.jamda.2017.12.079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The population of older adults residing in assisted living facilities (ALF) in the United States is growing, yet health data about this population is relatively sparse. We aimed to compare health outcomes of ALF residents with those of age- and sex-matched community dwelling adults in a retrospective cohort study of 808 older adults. Linear regression analyses were conducted to describe the relationship between ALF residency and our outcomes of hospitalizations within 1 year of the index date (earliest recorded date in the ALF), 30-day rehospitalization following index hospitalization, emergency department (ED) visits, and mortality at 1 year. Hospitalizations were significantly greater for ALF residents than for controls. The odds of death for ALF residents were approximately twice that of controls. Falls and ED visits were also significantly greater for ALF residents. The ALF population requires targeted geriatric and primary care models if we are to effectively meet the needs of this growing population.
Collapse
Affiliation(s)
- Mairead M Bartley
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephanie M Quigg
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anupam Chandra
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Paul Y Takahashi
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
9
|
Wall J, Hiestand B, Caterino J. Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department. West J Emerg Med 2015; 16:966-73. [PMID: 26759640 PMCID: PMC4703171 DOI: 10.5811/westjem.2015.8.25657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/28/2015] [Accepted: 08/31/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction We conducted an epidemiologic evaluation of advance directives and do-not-resuscitate (DNR) prevalence among residents of extended care facilities (ECF) presenting to the emergency department (ED). Methods We performed a retrospective medical record review on ED patients originating from an ECF. Data were collected on age, sex, race, triage acuity, ED disposition, DNR status, power-of attorney (POA) status, and living will (LW) status. We generated descriptive statistics, and used logistic regression to evaluate predictors of DNR status. Results A total of 754 patients over 20 months met inclusion criteria; 533 (70.7%) were white, 351 (46.6%) were male, and the median age was 66 years (IQR 54–78). DNR orders were found in 124 (16.4%, 95% CI [13.9–19.1%]) patients. In univariate analysis, there was a significant difference in DNR by gender (10.5% female vs. 6.0% male with DNR, p=0.013), race (13.4% white vs. 3.1% non-white with DNR, p=0.005), and age (4.0% <65 years; 2.9% 65–74 years, p=0.101; 3.3% 75–84 years, p=0.001; 6.2% >84 years, p<0.001). Using multivariate logistic regression, we found that factors associated with DNR status were gender (OR 1.477, p=0.358, note interaction term), POA status (OR 6.612, p<0.001), LW (18.032, p<0.001), age (65–74 years OR 1.261, p=0.478; 75–84 years OR 1.737, p=0.091, >84 years OR 5.258, P<0.001), with interactions between POA and gender (OR 0.294, P=0.016) and between POA and LW (OR 0.227, p<0.005). Secondary analysis demonstrated that DNR orders were not significantly associated with death during admission (p=0.084). Conclusion Age, gender, POA, and LW use are predictors of ECF patient DNR use. Further, DNR presence is not a predictor of death in the hospital.
Collapse
Affiliation(s)
- Jessica Wall
- Penn Presbyterian Medical Center, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Brian Hiestand
- Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina
| | - Jeffrey Caterino
- Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| |
Collapse
|
10
|
Khosla N, Curl AL, Washington KT. Trends in Engagement in Advance Care Planning Behaviors and the Role of Socioeconomic Status. Am J Hosp Palliat Care 2015; 33:651-7. [PMID: 25900854 DOI: 10.1177/1049909115581818] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We investigated the trends in advance care planning (ACP) between 2002 and 2010 and whether socioeconomic status explained such trends. We conducted a pooled regression analysis of Health and Retirement Study data from 6052 proxies of deceased individuals. We studied 3 ACP behaviors, discussing end-of-life (EOL) care preferences, providing written EOL care instructions, and appointing a durable power of attorney for health care (DPAHC). ACP increased by 12% to 23% every 2 years from 2002 to 2010. Higher household income increased the odds of having a DPAHC. Education was not associated with ACP. Socioeconomic status alone appears to play a very limited role in predicting ACP. Engagement in ACP likely depends on a constellation of many social and contextual factors.
Collapse
Affiliation(s)
- Nidhi Khosla
- Department of Health Sciences, University of Missouri, Columbia, MO, USA
| | - Angela L Curl
- School of Social Work, University of Missouri, Columbia, MO, USA
| | - Karla T Washington
- Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, MO, USA
| |
Collapse
|
11
|
Zimmerman S, Cohen L, van der Steen JT, Reed D, van Soest-Poortvliet MC, Hanson LC, Sloane PD. Measuring end-of-life care and outcomes in residential care/assisted living and nursing homes. J Pain Symptom Manage 2015; 49:666-79. [PMID: 25205231 DOI: 10.1016/j.jpainsymman.2014.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 08/08/2014] [Accepted: 08/14/2014] [Indexed: 10/24/2022]
Abstract
CONTEXT The two primary residential options for older adults who require supportive care are nursing homes and residential care/assisted living. More than one-quarter of all deaths in the U.S. occur in these settings. Although the information available on end of life in long-term care has been growing, the comparative suitability of various measures to guide this work is unknown. OBJECTIVES To determine the optimal measures to assess end-of-life care and outcomes in nursing homes and residential care/assisted living. METHODS A total of 264 family members of decedents from 118 settings were interviewed and provided data on 11 instruments that have been used in, but not necessarily developed for, long-term care populations; Overall, 20 scales and subscales/indices were evaluated. Measures were compared on their psychometric properties and the extent to which they discriminated among important resident, family, and setting characteristics. RESULTS Prioritizing measures that distinguish the assessment of care from the assessment of dying, and secondarily that exhibit an acceptable factor structure, this study recommends two measures of care-the Family Perceptions of Physician-Family Caregiver Communication and the End of Life in Dementia (EOLD)-Satisfaction With Care-and two measures of outcomes-the EOLD-Symptom Management and the EOLD-Comfort Assessment in Dying. An additional measure to assess outcomes is the Mini-Suffering State Examination (MSSE). The care measures and the MSSE are especially valuable as they discriminate between decedents who were and were not transferred immediately before death, an important outcome, and whether the family expected the death, a useful target for intervention. CONCLUSION Despite these recommendations, measurement selection should be informed not only on the basis of psychometric properties but also by specific clinical and research needs. The data in this manuscript will help researchers, clinicians, and administrators understand the implications of choosing various measures for their work.
Collapse
Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Lauren Cohen
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Medicine Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jenny T van der Steen
- Department of Nursing Home Medicine, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands; Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Amsterdam, The Netherlands
| | - David Reed
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Laura C Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Medicine Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
12
|
Implementation of a Facilitated Advance Care Planning Process in an Assisted Living Facility. J Hosp Palliat Nurs 2014. [DOI: 10.1097/njh.0000000000000033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
13
|
|
14
|
De Gendt C, Bilsen J, Stichele RV, Deliens L. Advance care planning and dying in nursing homes in Flanders, Belgium: a nationwide survey. J Pain Symptom Manage 2013; 45:223-34. [PMID: 22917717 DOI: 10.1016/j.jpainsymman.2012.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 02/06/2012] [Accepted: 02/14/2012] [Indexed: 11/28/2022]
Abstract
CONTEXT In Belgium, data on actual advance care planning (ACP) in nursing homes (NHs) are scarce. OBJECTIVES To investigate the prevalence and characteristics of documented advance directives and physicians' orders for end-of-life care in NHs, and the authorization of a legal representative in relation to the residents' demographic and clinical characteristics and care received. METHODS This was a retrospective cross-sectional study, including all NH residents deceased during September and October 2006 in all 594 NHs in Flanders, Belgium. Structured mail questionnaires about the resident's characteristics, hospital transfers, palliative care delivery, ACPs, and authorization of legal representatives were completed via the NH administrators and nurses involved in the care of the resident. RESULTS Administrators of 318 NHs (53.5%) reported 1303 deaths. Nurses provided information about 1240 (95.2%) of these deaths. At the end of life, NH residents often had dementia (65.2%) and were severely dependent (76.1%). Almost half (43.1%) had at least one hospital transfer during the last three months of life and two-thirds received palliative care. Half had an ACP, predominantly a physician's order and less often an advance directive. Having advance directives or physician's orders was associated with receiving palliative care. Residents with a physician's order more often died in the NH. Nine percent had an authorized legal representative. CONCLUSION Prevalence of ACPs and formal authorization of a legal representative was low among the deceased NH residents in Flanders, Belgium. There was a higher prevalence of physicians' orders, often established after the resident had lost capacity. Initiatives should be developed to stimulate more advance discussion on care options and making end-of-life decision with the residents while they retain capacity.
Collapse
Affiliation(s)
- Cindy De Gendt
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | |
Collapse
|
15
|
Silvester W, Fullam RS, Parslow RA, Lewis VJ, Sjanta R, Jackson L, White V, Gilchrist J. Quality of advance care planning policy and practice in residential aged care facilities in Australia. BMJ Support Palliat Care 2012; 3:349-57. [PMID: 24644755 PMCID: PMC3756507 DOI: 10.1136/bmjspcare-2012-000262] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP. DESIGN Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures. SETTING 19 selected RACFs in Victoria. PARTICIPANTS 12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour. RESULTS Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support. CONCLUSIONS Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.
Collapse
Affiliation(s)
- William Silvester
- Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Advance directives and physicians' orders in nursing home residents with dementia in Flanders, Belgium: prevalence and associated outcomes. Int Psychogeriatr 2012; 24:1133-43. [PMID: 22364648 DOI: 10.1017/s1041610212000142] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Advance care planning (ACP) is an important element of high-quality care in nursing homes, especially for residents having dementia who are often incompetent in decision-making toward the end of life. The aim of this study was describe the prevalence of documented ACP among nursing home residents with dementia in Flanders, Belgium, and associated clinical characteristics and outcomes. METHODS All 594 nursing homes in Flanders were asked to participate in a retrospective cross-sectional postmortem survey in 2006. Participating homes identified all residents who had died over the last two months. A structured questionnaire was mailed to the nurses closely involved in the deceased resident's care regarding the diagnosis of dementia and documented care planning, i.e. advance patient directives, authorization of a legal representative, and general practitioners' treatment orders (GP orders). RESULTS In 345 nursing homes (58% response rate), nurses identified 764 deceased residents with dementia of whom 62% had some type of documented care plan, i.e. advance patient directives in 3%, a legal representative in 8%, and GP orders in 59%. Multivariate logistic regression showed that the presence of GP orders was positively associated with receiving specialist palliative care in the nursing home (OR 3.10; CI, 2.07-4.65). Chances of dying in a hospital were lower if there was a GP order (OR 0.38; CI, 0.21-0.70). CONCLUSIONS Whereas GP orders are relatively common among residents with dementia, advance patient directives and a legal representative are relatively uncommon. Nursing home residents receiving palliative care are more likely to have a GP order. GP orders may affect place of death.
Collapse
|
17
|
Dobbs D, Meng H, Hyer K, Volicer L. The influence of hospice use on nursing home and hospital use in assisted living among dual-eligible enrollees. J Am Med Dir Assoc 2011; 13:189.e9-189.e13. [PMID: 21763210 DOI: 10.1016/j.jamda.2011.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents. DESIGN The study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment. SETTING A total of 328 licensed AL communities accepting Medicaid waivers in Florida. PARTICIPANTS We identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months. MEASUREMENTS Using the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data. RESULTS The mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence. CONCLUSIONS Hospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.
Collapse
Affiliation(s)
- Debra Dobbs
- Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, FL, USA.
| | | | | | | |
Collapse
|
18
|
Bravo G, Dubois MF, Cohen C, Wildeman S, Graham J, Painter K, Bellemare S. Are Canadians providing advance directives about health care and research participation in the event of decisional incapacity? CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2011; 56:209-18. [PMID: 21507277 DOI: 10.1177/070674371105600404] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Advance planning for health care and research participation has been promoted as a mechanism to retain some control over one's life, and ease substitute decision making, in the event of decisional incapacity. Limited data are available on Canadians' current advance planning activities. We conducted a postal survey to estimate the frequency with which Canadians communicate their preferences about health care and research should they become incapacitated. METHOD We surveyed 5 populations (older adults, informal caregivers, physicians, researchers in aging, and research ethics board members) from Nova Scotia, Ontario, Alberta, and British Columbia. We asked respondents whether they had expressed their preferences regarding a substitute decision maker, health care, and research participation in the event of incapacity. RESULTS Two out of 3 respondents (62.0%; 95% CI 59.1% to 64.8%) had been advised to communicate their health care preferences in advance. Oral expression of wishes was reported by 69.1% of respondents (95% CI 66.8% to 71.3%), and written expression by 46.7% (95% CI 44.3% to 49.2%). Among respondents who had expressed wishes in advance (orally or in writing), 91.2% had chosen a substitute decision maker, 80.9% had voiced health care preferences, and 19.5% had voiced preferences regarding research participation. Having been advised to communicate wishes was a strong predictor of the likelihood of having done so. CONCLUSIONS Advance planning has increased over the last 2 decades in Canada. Nonetheless, further efforts are needed to encourage Canadians to voice their health care and research preferences in the event of incapacity. Physicians are well situated to promote advance planning to Canadians.
Collapse
Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, University of Sherbrooke, Sherbrooke, Quebec.
| | | | | | | | | | | | | |
Collapse
|
19
|
Krok J, Dobbs D, Hyer K, Polivka-West L. Nurse managers' perspectives of structural and process characteristics related to residents' advance directives in nursing homes. Appl Nurs Res 2011; 24:e45-50. [PMID: 21439787 DOI: 10.1016/j.apnr.2010.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/17/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
This article examines associations between nursing home structural and process characteristics and presence of advance directives and trends over 5 years of advance directives in Florida nursing homes. Our results underscore the importance of nursing homes' processes in facilitating discussions of nursing home residents' end-of-life care preferences.
Collapse
Affiliation(s)
- Jessica Krok
- University of South Florida, School of Aging Studies and Florida Policy Exchange Center on Aging, Tampa, 33612, USA.
| | | | | | | |
Collapse
|
20
|
Philpot C, Tolson D, Morley JE. Advanced Practice Nurses and Attending Physicians: A Collaboration to Improve Quality of Care in the Nursing Home. J Am Med Dir Assoc 2011; 12:161-5. [DOI: 10.1016/j.jamda.2010.12.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 12/13/2010] [Indexed: 12/19/2022]
|
21
|
Hirschman KB, Abbott KM, Hanlon AL, Prvu Bettger J, Naylor MD. What factors are associated with having an advance directive among older adults who are new to long term care services? J Am Med Dir Assoc 2011; 13:82.e7-11. [PMID: 21450235 DOI: 10.1016/j.jamda.2010.12.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 12/09/2010] [Accepted: 12/13/2010] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To explore differences in having an advance directive among older adults newly transitioned to long term services and support (LTSS) settings (ie, nursing homes [NHs]; assisted living facilities [ALFs]; home and community-based services). DESIGN Cross sectional survey. SETTING LTSS in New York and Pennsylvania. PARTICIPANTS Participants were 470 older adults who recently started receiving LTSS. Included in this analyses, N = 442 (ALF: n = 153; NH: n = 145; home and community-based services: n = 144). MEASUREMENTS Interviews consisted of questions about advance directives (living will and health care power of attorney), significant health changes in the 6 months before the start of long term care support services, Mini-Mental State Examination, and basic demographics. RESULTS Sixty-one percent (270/442) of older adults receiving LTSS reported having either a living will and/or an health care power of attorney. ALF residents reported having an advance directive more frequently than NH residents and older adults receiving LTSS in their own home (living will: χ(2)[2]= 120.9; P < .001; health care power of attorney: χ(2)[2]= 69.1; P < .001). In multivariate logistic regression models, receiving LTSS at an ALF (OR = 5.01; P < .001), being white (OR = 2.87; P < .001), having more than 12 years of education (OR = 2.50; P < .001), and experiencing a significant health change in past 6 months (OR = 1.97; P = .007) were predictive of having a living will. Receiving LTSS at an ALF (OR = 4.16; P < .001), having more than 12 years of education (OR = 1.74, P = .022), and having had a significant change in health in the last 6 months (OR = 1.61; P = .037) were predictive in having an health care power of attorney in this population of LTSS recipients. CONCLUSIONS These data provide insight into advance directives and older adults new to LTSS. Future research is needed to better understand the barriers to completing advance directives before and during enrollment in LTSS as well as to assess advance directive completion changes over time for this population of older adults.
Collapse
Affiliation(s)
- Karen B Hirschman
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
22
|
Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest 2011; 139:1025-1033. [PMID: 21292758 DOI: 10.1378/chest.10-3011] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status. METHODS We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services. RESULTS Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care. CONCLUSIONS We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Sarah Muni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA
| | - Ruth A Engelberg
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Patsy D Treece
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Danae Dotolo
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - J Randall Curtis
- Harborview Medical Center and the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA.
| |
Collapse
|
23
|
Burgess M, Cha S, Tung EE. Advance care planning in the skilled nursing facility: what do we need for success? Hosp Pract (1995) 2011; 39:85-90. [PMID: 21441763 DOI: 10.3810/hp.2011.02.378] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Despite the established benefits of advance care planning (ACP) in the geriatric population, documentation of ACP counseling in the skilled nursing facility (SNF) setting remains poor. The primary aim of this study was to identify key barriers to ACP completion among SNF providers. A secondary aim was to identify ACP practice-based differences between SNF physicians and midlevel providers. METHODS As part of a divisional quality improvement project, 43 SNF providers from the area's 9 facilities were asked to complete an optional 14-item electronic survey. The survey was designed to explore and contrast SNF physicians' and midlevel providers' experiences with ACP counseling and documentation. RESULTS We obtained a 91% completion rate. Systems-based factors, such as lack of a centralized document location, inconsistent documentation habits, dispersion of responsibility, lack of time, and under-recognition of team members' efforts, were cited as key barriers to ACP documentation. Perceived patient characteristics contributing to a low completion rate included cognitive impairment and lack of family involvement. Key differences between the 2 provider groups included the location of their ACP documentation (electronic medical record vs paper chart), frequency of documentation, and recognition of who is documenting the ACP. CONCLUSION The survey demonstrated that systems-based barriers contribute to poor ACP documentation in the SNF setting. Key differences in attitudes about the impact of ACP on loved ones were identified between provider groups. Strategies aimed at mitigating practice-level barriers, such as standardizing a location for ACP documentation and formalizing workflow, are needed for increased ACP completion rates in SNFs.
Collapse
Affiliation(s)
- Mary Burgess
- Mayo Clinic, Internal Medicine Residency Program, Rochester, MN 55902, USA.
| | | | | |
Collapse
|
24
|
|
25
|
Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
26
|
Biola H, Sloane PD, Williams CS, Daaleman TP, Zimmerman S. Preferences versus practice: life-sustaining treatments in last months of life in long-term care. J Am Med Dir Assoc 2010; 11:42-51. [PMID: 20129214 DOI: 10.1016/j.jamda.2009.07.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/18/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST. DESIGN AND PARTICIPANTS After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility. SETTING The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states. MEASUREMENTS Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that. RESULTS Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034). CONCLUSION Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.
Collapse
Affiliation(s)
- Holly Biola
- Geriatrics Division, Department of Medicine, Duke University, Durham, NC, USA.
| | | | | | | | | |
Collapse
|