1
|
Auclair I, Bourbonnais A. The Involvement of Caregivers in the End-of-life Care of an Older Adult Living in a Long-term Care Home: A Qualitative Case Study with Nurses and Relatives. Can J Nurs Res 2024; 56:303-316. [PMID: 38619920 PMCID: PMC11308322 DOI: 10.1177/08445621241247862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND A key role of nurses working in long-term care homes (LTCHs) is to promote the involvement of care partners in end-of-life (EOL) care. However, studies on the involvement of care partners in EOL care in LTCHs have focused on care planning and decision-making. While care partners can participate in other ways, it's unclear how they are currently involved in EOL care by staff. PURPOSE We aimed to explore the involvement of care partners in the EOL care of an older adult living in a LTCH. METHODS A qualitative case study was conducted. Data was collected from a sample of four nurses and three care partners, using sociodemographic questionnaires, individual semi-structured interviews, documents pertaining to the LTCH's philosophy for EOL care, and a field diary. RESULTS The results of a thematic analysis showed the broad scope of care partners' possible involvement, including contributing to care, obtaining information, and being present. As there was some variation in care partners' desire to be involved, nurses seemed to rely on them to convey their wishes. To promote this involvement, some strategies aimed at health professionals and managers were suggested. CONCLUSIONS These results can guide improvement in clinical practices and raise awareness on the EOL care experiences of care partners.
Collapse
Affiliation(s)
- Isabelle Auclair
- PhD candidate, Faculty of Nursing, Université de Montréal, Montreal, Canada
- Research assistant, Research Centre of the Institut universitaire de gériatrie de Montréal, Montreal, Canda
| | - Anne Bourbonnais
- Full professor, Faculty of Nursing, Université de Montréal, Montreal, Canada
- Researcher, Research Centre of the Institut universitaire de gériatrie de Montréal, Montreal, Canada
- Chairholder of the Canada Research Chair in Care for Older People Chairholder of the Research Chair in Nursing Care for Older People and their Families, Montreal, Canada
| |
Collapse
|
2
|
Nolan VJ, Balch JA, Baskaran NP, Shickel B, Efron PA, Upchurch GR, Bihorac A, Tignanelli CJ, Moseley RE, Loftus TJ. Incorporating Patient Values in Large Language Model Recommendations for Surrogate and Proxy Decisions. Crit Care Explor 2024; 6:e1131. [PMID: 39132980 PMCID: PMC11321752 DOI: 10.1097/cce.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Surrogates, proxies, and clinicians making shared treatment decisions for patients who have lost decision-making capacity often fail to honor patients' wishes, due to stress, time pressures, misunderstanding patient values, and projecting personal biases. Advance directives intend to align care with patient values but are limited by low completion rates and application to only a subset of medical decisions. Here, we investigate the potential of large language models (LLMs) to incorporate patient values in supporting critical care clinical decision-making for incapacitated patients in a proof-of-concept study. METHODS We simulated text-based scenarios for 50 decisionally incapacitated patients for whom a medical condition required imminent clinical decisions regarding specific interventions. For each patient, we also simulated five unique value profiles captured using alternative formats: numeric ranking questionnaires, text-based questionnaires, and free-text narratives. We used pre-trained generative LLMs for two tasks: 1) text extraction of the treatments under consideration and 2) prompt-based question-answering to generate a recommendation in response to the scenario information, extracted treatment, and patient value profiles. Model outputs were compared with adjudications by three domain experts who independently evaluated each scenario and decision. RESULTS AND CONCLUSIONS Automated extractions of the treatment in question were accurate for 88% (n = 44/50) of scenarios. LLM treatment recommendations received an average Likert score by the adjudicators of 3.92 of 5.00 (five being best) across all patients for being medically plausible and reasonable treatment recommendations, and 3.58 of 5.00 for reflecting the documented values of the patient. Scores were highest when patient values were captured as short, unstructured, and free-text narratives based on simulated patient profiles. This proof-of-concept study demonstrates the potential for LLMs to function as support tools for surrogates, proxies, and clinicians aiming to honor the wishes and values of decisionally incapacitated patients.
Collapse
Affiliation(s)
| | - Jeremy A. Balch
- Department of Surgery, University of Florida, Gainesville, FL
| | | | | | - Philip A. Efron
- Department of Surgery, University of Florida, Gainesville, FL
| | | | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL
| | | | - Ray E. Moseley
- College of Medicine, University of Florida, Gainesville, FL
| | - Tyler J. Loftus
- Department of Surgery, University of Florida, Gainesville, FL
| |
Collapse
|
3
|
Tanuseputro P, Roberts RL, Milani C, Clarke AE, Webber C, Isenberg SR, Kobewka D, Turcotte L, Bush SH, Boese K, Arya A, Robert B, Sinnarajah A, Simon JE, Howard M, Lau J, Qureshi D, Fremont D, Downar J. Palliative End-of-Life Medication Prescribing Rates in Long-Term Care: A Retrospective Cohort Study. J Am Med Dir Assoc 2024; 25:532-538.e8. [PMID: 38242534 DOI: 10.1016/j.jamda.2023.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Medications are often needed to manage distressing end-of-life symptoms (eg, pain, agitation). OBJECTIVES In this study, we describe the variation in prescribing rates of symptom relief medications at the end of life among long-term care (LTC) decedents. We evaluate the extent these medications are prescribed in LTC homes and whether prescribing rates of end-of-life symptom management can be used as an indicator of quality end-of-life care. DESIGN Retrospective cohort study using administrative health data. SETTING AND PARTICIPANTS LTC decedents in all 626 publicly funded LTC homes in Ontario, Canada, between January 1, 2017, and March 17, 2020. METHODS For each LTC home, we measured the percent of decedents who received 1+ prescription(s) for a subcutaneous end-of-life symptom management medication ("end-of-life medication") in their last 14 days of life. We then ranked LTC homes into quintiles based on prescribing rates. RESULTS We identified 55,916 LTC residents who died in LTC. On average, two-thirds of decedents (64.7%) in LTC homes were prescribed at least 1 subcutaneous end-of-life medication in the last 2 weeks of life. Opioids were the most common prescribed medication (overall average prescribing rate of 62.7%). LTC homes in the lowest prescribing quintile had a mean of 37.3% of decedents prescribed an end-of-life medication, and the highest quintile mean was 82.5%. In addition, across these quintiles, the lowest prescribing quintile had a high average (30.3%) of LTC residents transferred out of LTC in the 14 days compared with the highest prescribing quintile (12.7%). CONCLUSIONS AND IMPLICATIONS Across Ontario's LTC homes, there are large differences in prescribing rates for subcutaneous end-of-life symptom relief medications. Although future work may elucidate why the variability exists, this study provides evidence that administrative data can provide valuable insight into the systemic delivery of end-of-life care.
Collapse
Affiliation(s)
- Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Rhiannon L Roberts
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christina Milani
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Anna E Clarke
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Daniel Kobewka
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Luke Turcotte
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Kaitlyn Boese
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Amit Arya
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Research Institute, Toronto, Ontario, Canada
| | - Benoit Robert
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
| | | | - Jessica E Simon
- Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Lau
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Deena Fremont
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| |
Collapse
|
4
|
Toles M, Kistler C, Lin FC, Lynch M, Wessell K, Mitchell SL, Hanson LC. Palliative care for persons with late-stage Alzheimer's and related dementias and their caregivers: protocol for a randomized clinical trial. Trials 2023; 24:606. [PMID: 37743478 PMCID: PMC10518941 DOI: 10.1186/s13063-023-07614-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Limited access to specialized palliative care exposes persons with late-stage Alzheimer's disease and related dementias (ADRD) to burdensome treatment and unnecessary hospitalization and their caregivers to avoidable strain and financial burden. Addressing this unmet need, the purpose of this study was to conduct a randomized clinical trial (RCT) of the ADRD-Palliative Care (ADRD-PC) program. METHODS The study will use a multisite, RCT design and will be set in five geographically diverse US hospitals. Lead investigators and outcome assessors will be masked. The study will use 1:1 randomization of patient-caregiver dyads, and sites will enroll N = 424 dyads of hospitalized patients with late-stage ADRD with their family caregivers. Intervention dyads will receive the ADRD-PC program of (1) dementia-specific palliative care, (2) standardized caregiver education, and (3) transitional care. Control dyads will receive publicly available educational material on dementia caregiving. Outcomes will be measured at 30 days (interim) and 60 days post-discharge. The primary outcome will be 60-day hospital transfers, defined as visits to an emergency department or hospitalization ascertained from health record reviews and caregiver interviews (aim 1). Secondary patient-centered outcomes, ascertained from 30- and 60-day health record reviews and caregiver telephone interviews, will be symptom treatment, symptom control, use of community palliative care or hospice, and new nursing home transitions (aim 2). Secondary caregiver-centered outcomes will be communication about prognosis and goals of care, shared decision-making about hospitalization and other treatments, and caregiver distress (aim 3). Analyses will use intention-to-treat, and pre-specified exploratory analyses will examine the effects of sex as a biologic variable and the GDS stage. DISCUSSION The study results will determine the efficacy of an intervention that addresses the extraordinary public health impact of late-stage ADRD and suffering due to symptom distress, burdensome treatments, and caregiver strain. While many caregivers prioritize comfort in late-stage ADRD, shared decision-making is rare. Hospitalization creates an opportunity for dementia-specific palliative care, and the study findings will inform care redesign to advance comprehensive dementia-specific palliative care plus transitional care. TRIAL REGISTRATION ClinicalTrials.gov NCT04948866. Registered on July 2, 2021.
Collapse
Affiliation(s)
- M Toles
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - C Kistler
- Department of Family Medicine and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F C Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Lynch
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Wessell
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - L C Hanson
- Division of Geriatrics and Palliative Care Program, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
5
|
Serey K, Cambriel A, Pollina-Bachellerie A, Lotz JP, Philippart F. Advance Directives in Oncology and Haematology: A Long Way to Go-A Narrative Review. J Clin Med 2022; 11:jcm11051195. [PMID: 35268299 PMCID: PMC8911354 DOI: 10.3390/jcm11051195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
Patients living with cancer often experience serious adverse events due to their condition or its treatments. Those events may lead to a critical care unit admission or even result in death. One of the most important but challenging parts of care is to build a care plan according to the patient’s wishes, meeting their goals and values. Advance directives (ADs) allow everyone to give their preferences in advance regarding life sustaining treatments, continuation, and withdrawal or withholding of treatments in case one is not able to speak their mind anymore. While the absence of ADs is associated with a greater probability of receiving unwanted intensive care around the end of their life, their existence correlates with the respect of the patient’s desires and their greater satisfaction. Although progress has been made to promote ADs’ completion, they are still scarcely used among cancer patients in many countries. Several limitations to their acceptance and use can be detected. Efforts should be made to provide tailored solutions for the identified hindrances. This narrative review aims to depict the situation of ADs in the oncology context, and to highlight the future areas of improvement.
Collapse
Affiliation(s)
- Kevin Serey
- Anesthesiology and Intensive Care Medicine Department, APHP—Ambroise Paré University Hospital, 92100 Boulogne-Billancourt, France;
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
| | - Amélie Cambriel
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, 75020 Paris, France
| | - Adrien Pollina-Bachellerie
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Anesthesiology and Intensive Care Medicine Department, Toulouse Hospitals, 31000 Toulouse, France
| | - Jean-Pierre Lotz
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Pôle Onco-Hématologie, Service D’oncologie Médicale et de Thérapie Cellulaire, APHP—Hôpitaux Universitaires de L’est Parisien, 75020 Paris, France
| | - François Philippart
- REQUIEM (Research/Reflexion on End of Life Support Quality in Everyday Medical Practice) Study Group, 75015 Paris, France; (A.C.); (A.P.-B.); (J.-P.L.)
- Medical and Surgical Intensive Care Department, Groupe Hospitalier Paris Saint Joseph, 185 Rue R. Losserand, 75674 Paris, France
- Correspondence: ; Tel.: +33-1-44-12-30-85
| |
Collapse
|
6
|
Bravo G, Van den Block L, Downie J, Arcand M, Trottier L. Attitudes toward withholding antibiotics from people with dementia lacking decisional capacity: findings from a survey of Canadian stakeholders. BMC Med Ethics 2021; 22:119. [PMID: 34488722 PMCID: PMC8420012 DOI: 10.1186/s12910-021-00689-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity. Methods We conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death. Results Support for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics. Conclusions Findings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00689-1.
Collapse
Affiliation(s)
- Gina Bravo
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada. .,Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada.
| | - Lieve Van den Block
- VUB-UGhent End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jocelyn Downie
- Schulich School of Law and Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Marcel Arcand
- Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada.,Department of Family Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lise Trottier
- Research Centre On Aging, CIUSSS de l'Estrie - CHUS, 1036 South Belvedere Street, Sherbrooke, J1H 4C4, Canada
| |
Collapse
|
7
|
Master JF, Wu B, Ni P, Mao J. The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review. J Am Med Dir Assoc 2021; 22:2273-2280.e2. [PMID: 34087224 DOI: 10.1016/j.jamda.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults. DESIGN A scoping review was used to identify key themes in the compliance of EOL care preferences among older adults. SETTING AND PARTICIPANTS Studies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected. MEASURES The eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components. RESULTS In total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP. CONCLUSIONS/IMPLICATIONS The compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.
Collapse
Affiliation(s)
- Jie Fu Master
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bei Wu
- Rory Meyers College of Nursing and NYU Aging Incubator, New York University, New York, NY, USA
| | - Ping Ni
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| |
Collapse
|
8
|
Bandini JI, Schlang D, Kim H, Bradley M, Price RA, Bunker JN, Teno JM. "If We Turned Our Backs, They Would Ignore Our Wishes": Bereaved Family Perceptions of Concordance of Care at the End of Life. J Palliat Med 2021; 24:1667-1672. [PMID: 33826426 DOI: 10.1089/jpm.2020.0714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The key to high-quality care at the end of life is goal-concordant care, defined as care that is consistent with patient wishes. Objectives: To characterize decedent wishes for care at the end of life and to examine next of kin narratives of their loved ones' perceptions of whether wishes were honored. Design: Mortality follow-back survey and in-depth interviews. Setting/Subjects: Survey responses (n = 601) were from next of kin of decedents who died in the San Francisco Bay area of the United States. Interviews were conducted with 51 next of kin, of whom 14 indicated that the decedent received care that was inconsistent with their wishes. Measurements: The survey asked if the decedent had wishes or plans for care and if care provided ever went against those wishes. In-depth interviews focused on aspects of care at the end of life that were not consistent with the decedent's wishes. Results: Approximately 10% of next of kin who reported on the survey that the decedent had specific wishes for medical care at the end of life also reported that the decedent received care that went against their wishes in the last month of life. The main theme of the in-depth interviews with next of kin who reported care that went against wishes was that discordant care was inconsistent with wishes for comfort-focused care and a lack of symptom palliation. Conclusions: Despite decades of work to improve quality of end-of-life care, poor pain and symptom management that result in lack of comfort remain the main reason that next of kin state wishes were not honored.
Collapse
Affiliation(s)
| | | | - Hyosin Kim
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | | | | | - Jennifer N Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| |
Collapse
|
9
|
Yeh T, Huang H, Yeh T, Huang W, Huang H, Chang Y, Chen W. Family members' concerns about relatives in long‐term care facilities: Acceptance of visiting restriction policy amid the
COVID
‐19 pandemic. Geriatr Gerontol Int 2020; 20:938-942. [DOI: 10.1111/ggi.14022] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/03/2020] [Accepted: 08/04/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ting‐Chun Yeh
- Department of Community Health Ditmanson Medical Foundation Chiayi Christian Hospital Chiayi Taiwan
| | | | - Ting‐Yu Yeh
- Department of Community Service Ditmanson Medical Foundation Chiayi Christian Hospital Chiayi Taiwan
| | - Wan‐Ting Huang
- Clinical Medicine Research Center Ditmanson Medical Foundation Chiayi Christian Hospital Chiayi Taiwan
| | - Hsiu‐Chen Huang
- Department of Community Health Ditmanson Medical Foundation Chiayi Christian Hospital Chiayi Taiwan
| | | | - Wei Chen
- Department of Community Health Ditmanson Medical Foundation Chiayi Christian Hospital Chiayi Taiwan
| |
Collapse
|
10
|
Dowson L, Friedman ND, Marshall C, Stuart RL, Buising K, Rajkhowa A, Gotterson F, Kong DC. Antimicrobial stewardship near the end of life in aged care homes. Am J Infect Control 2020; 48:688-694. [PMID: 31806238 DOI: 10.1016/j.ajic.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. METHODS Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. RESULTS Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. CONCLUSIONS Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.
Collapse
|
11
|
Duberstein PR, Chen M, Hoerger M, Epstein RM, Perry LM, Yilmaz S, Saeed F, Mohile SG, Norton SA. Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review. J Pain Symptom Manage 2020; 59:894-915.e14. [PMID: 31639495 PMCID: PMC8928482 DOI: 10.1016/j.jpainsymman.2019.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care. OBJECTIVE The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice. METHODS We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored. RESULTS We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs. CONCLUSION Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.
Collapse
Affiliation(s)
- Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers University School of Public Health, Piscataway, New Jersey, USA.
| | - Michael Chen
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA; Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA
| | - Ronald M Epstein
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Laura M Perry
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Sule Yilmaz
- Margaret Warner School of Human Development, Rochester, New York, USA
| | - Fahad Saeed
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
| |
Collapse
|
12
|
Towsley GL, Wong B, Mokhtari T, Hull W, Miller SC. Piloting Me and My Wishes-Videos of Nursing Home Residents' Preferences. J Pain Symptom Manage 2020; 59:609-617. [PMID: 31711970 DOI: 10.1016/j.jpainsymman.2019.10.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT A key challenge in nursing homes (NHs) is how to attain and clarify resident preferences for care and then communicate these preferences to family members and staff. OBJECTIVES We evaluated the feasibility and acceptability of Me & My Wishes-person-centered videos of residents discussing their preferences for daily and end-of-life (EOL) care. METHODS For this descriptive study, Me & My Wishes videos were created with residents in three NHs in the Pacific Northwest. Feasibility was evaluated by tracking resident enrollment, completing and sharing their video, and conducting debriefing interviews to ascertain residents' impressions of the recording process and personalized conversation. After viewing the video, staff and family assessed communication quality via survey-the extent to which they perceived messages from the video (e.g., preferences for EOL) to be timely, accurate, adequate, complete, and credible and items on resident preferences for daily and EOL care. RESULTS Twenty of 33 residents approached created videos; 18 of these residents shared their videos with family or staff. Residents reported that they liked the opportunity to express their wishes. On a scale of 1-7 (lower is better), mean ratings were 2.0 (family) and 1.3 (staff) for communicating preferences for daily care; 1.9 (family) and 1.2 (staff) for communicating preferences for EOL. Both family and staff reported increased knowledge about resident preferences for daily and EOL care. CONCLUSION This research supports the feasibility and acceptability of a videotaping approach (Me & My Wishes) for viewing, listening, and discussing residents' preferences for daily and EOL care.
Collapse
Affiliation(s)
- Gail L Towsley
- University of Utah College of Nursing, Salt Lake City, Utah, USA.
| | - Bob Wong
- University of Utah College of Nursing, Salt Lake City, Utah, USA
| | | | - William Hull
- University of Utah College of Nursing, Salt Lake City, Utah, USA
| | - Susan C Miller
- Brown University School of Public Health, Providence, Rhode Island, USA
| |
Collapse
|
13
|
Buiar PG, Goldim JR. Barriers to the composition and implementation of advance directives in oncology: a literature review. Ecancermedicalscience 2019; 13:974. [PMID: 31921345 PMCID: PMC6946425 DOI: 10.3332/ecancer.2019.974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Indexed: 12/21/2022] Open
Abstract
The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.
Collapse
Affiliation(s)
- Pedro Grachinski Buiar
- Medical Oncology Department, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0001-5144-1197
| | - José Roberto Goldim
- Bioethics Division, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS 90035-007, Brazil
- http://orcid.org/0000-0003-2127-6594
| |
Collapse
|
14
|
Nemiroff L, Marshall EG, Jensen JL, Clarke B, Andrew MK. Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents. J Am Med Dir Assoc 2019; 20:1373-1381. [DOI: 10.1016/j.jamda.2019.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 10/26/2022]
|
15
|
Daneau S, Bourbonnais A, Legault A. Surrogates' end-of-life decision-making process in nursing homes for residents with a neurocognitive disorder: An integrative review. Int J Older People Nurs 2019; 15:e12274. [PMID: 31612638 DOI: 10.1111/opn.12274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The goal of this review is to analyse articles on the experience of surrogates who find themselves making end-of-life decisions for a relative with a major neurocognitive disorder in a nursing home. DESIGN An integrative review of the literature based on Whittemore and Knafl's method. DATA SOURCES This review used the CINAHL, PubMed, PsycInfo, Embase and Web of Science databases. A complementary search was also conducted via citation pearl searching, and the reference lists from the selected articles were manually verified. REVIEW METHOD The quality of the selected articles was assessed using the Crow Critical Appraisal Tool, and the data were extracted systematically and were then organised according to Mishel's uncertainty in illness theory. The data that did not correspond to any concept of the theory were excluded at this stage. Analysis was conducted using the method put forward by Miles, Huberman and Saldaña. RESULTS A total of 18 articles were selected: 11 qualitative, 5 quantitative and 1 using a mixed method, as well as 1 ethical argument. The subjects arising from the analysis of the articles were the types of decisions made, the support available for the surrogates, the role and involvement of the surrogates in the process and the factors that influence the decisions. CONCLUSION The results of this integrative review stimulate reflection on the needs of family members involved in making decisions, as well as on the nursing practice and research. Published literature is mainly from North America, and thus, more research is needed to better understand the impact of cultural and ethnic differences in the process, which was poorly covered by the existing literature. Also, exploring nurses' involvement in supporting surrogates may eventually better equip nurses for their interventions with surrogates. IMPLICATIONS FOR PRACTICE Describing the illness progression and the signification of palliative care to the resident with a NCD and their surrogate decision makers, as well as discussing end-of-life care preferences as early as possible are all nursing interventions that could potentially enhance surrogates' end-of-life decision-making process.
Collapse
Affiliation(s)
- Stéphanie Daneau
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Department of Nursing, Université du Québec à Trois-Rivières, Drummondville, QC, Canada
| | - Anne Bourbonnais
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada.,Research Chair in Nursing Care for Older People and their Families, Montréal, QC, Canada.,Research Center of the Institut universitaire de gériatrie de Montréal, Montréal, QC, Canada
| | - Alain Legault
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
| |
Collapse
|
16
|
McArthur C, Saari M, Northwood M, Taucar LS, Boscart VM. Profiling the Characteristics of People Who Are Comatose in Long-term and Complex Continuing Care Settings. J Am Med Dir Assoc 2019; 20:1331-1334. [PMID: 31230905 DOI: 10.1016/j.jamda.2019.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/22/2019] [Accepted: 04/25/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To describe the sociodemographic, clinical, and treatment characteristics of people who are comatose in Canadian complex continuing care (CCC) and long-term care (LTC) settings, and to make recommendations to promote comprehensive care planning for this population. DESIGN Retrospective, cross-sectional analysis of population data. SETTING AND PARTICIPANTS All residents in the Canadian provinces of Alberta, Ontario, British Columbia, Manitoba, Nova Scotia, Newfoundland, Saskatchewan, and the territory of Yukon with data available from the fiscal year 2015 (April 1, 2015, to March 31, 2016). MEASURES Demographic, clinical, and treatment variables were extracted from the Resident Assessment Instrument-Minimum Data Set (MDS 2.0) and were reported using descriptive statistics. RESULTS Of the LTC and CCC populations, 0.07% and 3.5% were identified as comatose, respectively. Overall, people who are comatose in both CCC or LTC settings are younger and have a longer length of stay than those who are not comatose. A higher proportion of people who are comatose experience active infections and irregular bowel elimination patterns, and those who are comatose were more likely to have a feeding tube and require oxygen therapy or suctioning than those who were not comatose. However, a lower proportion of people who were comatose had documented pain. In LTC, one-quarter of people who are comatose are expected to die within 6 months. CONCLUSION/IMPLICATIONS Although the prevalence of people who are comatose in LTC and CCC settings is low, this population is complex and has significant care needs that require comprehensive assessment and care planning.
Collapse
Affiliation(s)
- Caitlin McArthur
- GERAS Centre for Aging Research, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Margaret Saari
- Saint Elizabeth Health Care, Toronto, Ontario, Canada; School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Linda Sheiban Taucar
- Conestoga College, Schlegel Centre for Advancing Senior Care, Waterloo, Ontario, Canada; Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| | - Veronique M Boscart
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Conestoga College, Schlegel Centre for Advancing Senior Care, Waterloo, Ontario, Canada; Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
| |
Collapse
|
17
|
Oo NM, Scott IA, Maggacis R, Rajakaruna N. Assessing concordance between patient preferences in advance care plans and in-hospital care. AUST HEALTH REV 2019; 43:425-431. [DOI: 10.1071/ah18011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/20/2018] [Indexed: 11/23/2022]
Abstract
Objective
The aims of this study were to assess: (1) concordance between patient preferences stated in advance care plans (ACPs) and hospital care over the subsequent 12 months; (2) change in preferences over time; (3) justifications for discordant care; and (4) effects of ACP completion on hospital utilisation.
Methods
A retrospective study was conducted of 198 patients with an ACP form registered with an ACP registry and tagged with a hospital unique record number. Data collected from ACP forms and hospital records comprised ACP completion and revisions, care preferences, patient characteristics and hospital care. Instances of care discordant with preferences were analysed as Type A (no ascertainable justification) and Type B (direct patient request or appropriate clinical indications). In a survivor subset, hospital utilisation was compared before and after ACP completion.
Results
Mean (± s.d.) patient age was 79.5±11.8 years. Patients had a mean (± s.d.) of 5.5±2.5 comorbidities and 90 (46.4%) died within the 12 months after ACP completion. Most ACPs (130; 65.5%) were completed during index hospitalisation and 13 (6.5%) underwent revision, on average, 6.8 months later, all related to rescinding request for cardiopulmonary resuscitation. Hospital care was fully concordant for 154 (77.8%) patients, with 39 (22.2%) receiving 60 instances of discordant care (15 (25%) Type A, 45 (75%) Type B), mostly related to surgical procedures (20; 33%) and intravenous fluids or antibiotics (26; 43%). Patients receiving discordant care had higher mortality (77% vs 45%; P<0.001) and more rapid response team activations (34% vs 13%; P=0.001) at 12 months than patients with concordant care. Among the 108 confirmed survivors at 12 months after ACP completion, emergency department presentations and hospital admissions per patient had decreased by ≥50% (P<0.001) and hospital days had decreased by 25% (P=0.042) compared with the 12 months before ACP completion.
Conclusion
Most patients completing an ACP received hospital care fully concordant with their stated preferences, with few revising their preferences over time. Discordant care mostly related to justified supportive treatments or surgical procedures. Among survivors, ACP completion was associated with decreased use of hospital care.
What is known about the topic?
ACPs that list patient preferences and care goals relieve family and patient distress and uncertainty regarding future care decisions as death approaches, decrease unwanted medical interventions and hospitalisations, and are associated with more patients dying at home. However, uncertainty surrounds the extent to which in-patient care provided to patients’ concords with preferences stated in ACPs, which preferences are most adhered to, and whether preferences change over time, warranting revision of ACPs.
What does this paper add?
This retrospective study of 198 patients completing an ACP, of whom almost half died within the following 12 months, showed that more than 75% received hospital care fully concordant with their stated preferences and, for decedents, most died at their preferred place of death. Relatively few patients changed their documented preferences over time, and all changes were for less use of cardiopulmonary resuscitation (CPR). Instances of discordant care mostly related to the administration of supportive treatments or surgical procedures and most were justified on the basis of patient request or appropriate clinical indications. Among 108 survivors, the number of emergency department presentations and hospital admissions per patient at 12 months after ACP completion was half those seen in the 12 months before ACP completion, whereas hospital days per patient decreased by 25%.
What are the implications for practitioners?
Encouraging patients with progressive chronic disease to complete an ACP reduces their risk of receiving care they do not want, reflected in decreased use of hospital care. Preferences stated in ACPs are mostly stable over time and, if changed, tend to become more conservative in terms of CPR. Conversely, preferences stated in the ACP do not, as circumstances change, bind patients or clinicians to withholding care that relieves symptoms or prevents major morbidity in the short term.
Collapse
|
18
|
Gill C, Hillier LM, Crandall JM, Johnston J. Nursing Guidelines for End-Of-Life Care in Long-Term Care Settings: Sustainable Improvements to Care. J Palliat Care 2018. [DOI: 10.1177/082585971102700308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Carole Gill
- LM Hillier (corresponding author) Specialized Geriatric Services, St. Joseph's Health Care London, and Aging, Rehabilitation and Geriatric Care Research Centre, Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada, N6C 5J1
| | - Loretta M. Hillier
- Palliative Pain and Symptom Management Consultation Program—Southwestern Ontario, Windsor, Ontario, Canada
| | - Jacqueline M. Crandall
- London Health Sciences Centre; Faculty of Nursing, University of Western Ontario; and Department of Interdisciplinary Studies, King's University College, London, Ontario, Canada
| | - Julie Johnston
- Palliative Pain and Symptom Management Consultation Program— Southwestern Ontario, London, Ontario, Canada
| |
Collapse
|
19
|
Turley M, Wang S, Meng D, Garrido T, Kanter MH. The Feasibility of Automating Assessment of Concordance Between Advance Care Preferences and Care Received Near the End of Life. Jt Comm J Qual Patient Saf 2018; 45:123-130. [PMID: 30064952 DOI: 10.1016/j.jcjq.2018.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND End-of-life care is patient centered when it is concordant with patient preferences. Concordance has been frequently assessed by interview, chart review, or both. These time-consuming methods can constrain sample sizes, precluding population-level quality assessment. Concordance between preferences and care as measured by automated methods is described. METHODS Automated processes extracted and analyzed electronic health record (EHR) data to assess concordance between 15 advance care planning preference domains and 232 related end-of-life care events for 388 patients aged 65 years or older with an inpatient encounter at Kaiser Permanente Southern California who died during or after the encounter. Patient preferences were recorded in advance directives or physician orders or reflected in hospital code status. Concordance, assessed in relation to the most recent documents, orders, or code status, occurred when patients received care they preferred or did not receive nonpreferred care. Discordance occurred when patients received care they did not prefer or did not receive care they preferred. RESULTS Overall concordance for 12,592 observed end-of-life care events was 97.7%. A total of 55 of 4,154 (1.3%) received care events were nonpreferred, according to patient preferences in the EHR. Automated methods could not distinguish between medically nonbeneficial treatments, those that were not medically indicated, and potential undertreatment. CONCLUSION Automating assessment of concordance between care near the end of life and preferences is feasible but requires model refinement and discrete care preference data. Automated methods may be most valuable as a screening tool to identify potential overtreatment and undertreatment, with chart review to verify discordance.
Collapse
|
20
|
Sanders JJ, Curtis JR, Tulsky JA. Achieving Goal-Concordant Care: A Conceptual Model and Approach to Measuring Serious Illness Communication and Its Impact. J Palliat Med 2017; 21:S17-S27. [PMID: 29091522 DOI: 10.1089/jpm.2017.0459] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High-quality care for seriously ill patients aligns treatment with their goals and values. Failure to achieve "goal-concordant" care is a medical error that can harm patients and families. Because communication between clinicians and patients enables goal concordance and also affects the illness experience in its own right, healthcare systems should endeavor to measure communication and its outcomes as a quality assessment. Yet, little consensus exists on what should be measured and by which methods. OBJECTIVES To propose measurement priorities for serious illness communication and its anticipated outcomes, including goal-concordant care. METHODS We completed a narrative review of the literature to identify links between serious illness communication, goal-concordant care, and other outcomes. We used this review to identify gaps and opportunities for quality measurement in serious illness communication. RESULTS Our conceptual model describes the relationship between communication, goal-concordant care, and other relevant outcomes. Implementation-ready measures to assess the quality of serious illness communication and care include (1) the timing and setting of serious illness communication, (2) patient experience of communication and care, and (3) caregiver bereavement surveys that include assessment of perceived goal concordance of care. Future measurement priorities include direct assessment of communication quality, prospective patient or family assessment of care concordance with goals, and assessment of the bereaved caregiver experience. CONCLUSION Improving serious illness care necessitates ensuring that high-quality communication has occurred and measuring its impact. Measuring patient experience and receipt of goal-concordant care should be our highest priority. We have the tools to measure both.
Collapse
Affiliation(s)
- Justin J Sanders
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts.,3 Ariadne Labs , Boston, Massachusetts
| | - J Randall Curtis
- 4 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - James A Tulsky
- 1 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,2 Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| |
Collapse
|
21
|
Rosemond C, Hanson LC, Zimmerman S. Goals of Care or Goals of Trust? How Family Members Perceive Goals for Dying Nursing Home Residents. J Palliat Med 2017; 20:360-365. [PMID: 27898281 PMCID: PMC5385445 DOI: 10.1089/jpm.2016.0271] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF STUDY Dementia affects more than 5 million Americans, and is a leading cause of death. Family members of nursing home (NH) residents with advanced dementia report difficulty making decisions about care toward the end of life. As part of a randomized trial testing an intervention to improve decision making, this qualitative study aimed to understand how family decision makers experienced goal-based decision making in advance of the death of their relative. DESIGN AND METHODS This qualitative study was conducted as part of the goals of care clinical trial. Study participants (n = 16) were family decision makers in North Carolina whose relative with advanced dementia died after participating in the goals of care intervention. Semi-structured interviews were analyzed using a qualitative description approach. RESULTS Family members' experience of decision making and death differed based on the presence or absence of trusting relationships with NH staff. Family members who reported trust described a positive end-of-life experience and less need for prescribed goals of care discussions. In the absence of trust, family members reported that goals of care discussions were ignored by staff or created confusion. IMPLICATIONS Among family members of persons who recently died from dementia in NHs, expressions of trust in staff were strongly related to perceptions of decision making about goals of care. Although goals of care discussions may potentially promote communication to earn trust, the presence of pre-existing trust ultimately influenced the decision making and end-of-life experiences of residents and families.
Collapse
Affiliation(s)
- Cherie Rosemond
- Partnerships in Aging Program, University of North Carolina, Chapel Hill, North Carolina
| | - Laura C. Hanson
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina
| |
Collapse
|
22
|
Reinhardt JP, Downes D, Cimarolli V, Bomba P. End-of-Life Conversations and Hospice Placement: Association with Less Aggressive Care Desired in the Nursing Home. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2017; 13:61-81. [PMID: 28271977 DOI: 10.1080/15524256.2017.1282919] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Education about end-of-life care and treatment options, communication between family and health care providers, and having advance directives and medical orders in place are important for older adults with chronic, progressive decline and end-stage disease who spend their last days in the nursing home. This study used retrospective data (6 months before death) of long-stay nursing home decedents (N = 300) taken from electronic health records to capture the end-of-life experience. Findings showed for almost all decedents, Do Not Resuscitate and Do Not Intubate orders were in place, and just over one-half had Do Not Hospitalize and No Artificial Feeding orders in place. A small proportion had No Artificial Hydration or No Antibiotic orders in place. Overall, there was congruence between documented medical orders and treatment received. Findings showed that use of hospice and discussions about particular life-sustaining treatments each had significant associations with having less aggressive medical orders in place. These results can inform best practice development to promote high quality, person-directed, end-of-life care for nursing home residents.
Collapse
Affiliation(s)
- Joann P Reinhardt
- a Research Institute on Aging , The New Jewish Home , New York , New York , USA
| | | | - Verena Cimarolli
- a Research Institute on Aging , The New Jewish Home , New York , New York , USA
| | - Patricia Bomba
- c Excellus BlueCross BlueShield & MedAmerica Insurance Company , Rochester , New York , USA
| |
Collapse
|
23
|
Manu ER, Mody L, McNamara SE, Vitale CA. Advance Directives and Care Received by Older Nursing Home Residents. Am J Hosp Palliat Care 2016; 34:105-110. [PMID: 26494830 DOI: 10.1177/1049909115611875] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD). OBJECTIVE We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT), or both. Design/participants/measurements: A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. The ADs were divided as follows: (1) comfort oriented: comfort measures only, no hospital transfer; (2) palliative oriented: comfort focused, allowing hospital transfer (except intensive care unit), antibiotic use, but no cardiopulmonary resuscitation; (3) usual care: full code, no limitations to care. We calculated incidences for these outcomes. RESULTS Seventy-eight (87%) residents had ADs: 18 (23%) comfort oriented, 32 (41%) palliative oriented, and 28 (36%) usual care. The groups did not differ regarding demographics, comorbidity, function, device presence, or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (Incidence rate [IR] = 15.6/1000 follow-up days vs IR = 8.8/1000 follow-up days, Incident rate ratio [IRR] 0.6 [95% confidence interval, CI, 0.3 -1.1], P value .09) but received fewer antibiotics (IR = 18.9/1000 follow-up days vs IR = 7.5/1000 follow-up days, IRR 0.4 [95% CI, 0.2-0.8], P value .005). CONCLUSION Nursing home residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual-care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.
Collapse
Affiliation(s)
- Erika R Manu
- 1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| | - Lona Mody
- 1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| | - Sara E McNamara
- 1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| | - Caroline A Vitale
- 1 Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Ann Arbor, MI, USA
| |
Collapse
|
24
|
Hanson LC, Song MK, Zimmerman S, Gilliam R, Rosemond C, Chisholm L, Lin FC. Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia. Clin Trials 2016; 13:599-604. [PMID: 27271683 DOI: 10.1177/1740774516650863] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Ensuring fidelity to a behavioral intervention implemented in nursing homes requires awareness of the unique considerations of this setting for research. The purpose of this article is to describe the goals of care cluster-randomized trial and the methods used to monitor and promote fidelity to a goals of care decision aid intervention delivered in nursing homes. METHODS The cluster randomized trial tested whether a decision aid for goals of care in advanced dementia could improve (1) the quality of communication and decision-making, (2) the quality of palliative care, and (3) the quality of dying for nursing home residents with advanced dementia. In 11 intervention nursing homes, family decision-makers for residents with advanced dementia received a two-component intervention: viewing a video decision aid about goals of care choices and then participating in a structured decision-making discussion with the nursing home care plan team, ideally within 3 months after the decision aid was viewed. Following guidelines from the National Institutes of Health Behavior Change Consortium, fidelity was assessed in study design, in nursing home staff training for intervention implementation, and in monitoring and receipt of the intervention. We also monitored the content and timing of goals of care discussions. RESULTS Investigators enrolled 151 family decision-maker/resident dyads in intervention sites; of those, 136 (90%) received both components of the intervention, and 92%-99% of discussions addressed each of four recommended content areas-health status, goals of care, choice of a goal, and treatment planning. A total of 94 (69%) of the discussions between family decision-makers and the nursing home care team were completed within 3 months. CONCLUSION The methods we used for intervention fidelity allowed nursing home staff to implement a goals of care decision aid intervention for advanced dementia. Key supports for implementation included design features that aligned with nursing home practice, efficient staff training, and a structured guide for goals of care discussions between family decision-makers and staff. These approaches may be used to promote fidelity to behavioral interventions in future clinical trials.
Collapse
Affiliation(s)
- Laura C Hanson
- Geriatric Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mi-Kyung Song
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- Program on Aging, Disability and Long Term Care, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robin Gilliam
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cherie Rosemond
- Center for Health Promotion & Disease Prevention, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Latarsha Chisholm
- Department of Health Management and informatics, The University of Central Florida, Orlando, FL, USA
| | - Feng-Chang Lin
- Translational and Clinical Sciences Institute, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
25
|
Winn K, Ozanne E, Sepucha K. Measuring patient-centered care: An updated systematic review of how studies define and report concordance between patients' preferences and medical treatments. PATIENT EDUCATION AND COUNSELING 2015; 98:811-21. [PMID: 25846191 DOI: 10.1016/j.pec.2015.03.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 03/09/2015] [Accepted: 03/13/2015] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose was to examine recent advances in measuring value concordance and to highlight best practices. METHODS The paper updates a prior systematic review. A systematic review of the literature from 2008 to 2012 identified articles that reported a relationship between patients' preferences concerning health outcomes and/or medical treatments, and treatment (intended or actual). Relevant articles were independently abstracted by two reviewers. RESULTS The search identified 3635 unique citations, the full text of 187 articles was examined, and 63 articles covering 61 studies were included, nearly a third more articles than identified in the original review. There were 72 different value concordance calculations, the majority of which were clearly reported with significance. More studies assessed knowledge, reported on the association between value concordance and knowledge, and included a decision aid compared to those in the original review. CONCLUSION There is increased reporting of value concordance in the literature. However, large differences exist in the way that the measure is defined and calculated. The variability makes it difficult to draw conclusions about the quality of care across studies. PRACTICE IMPLICATIONS Value concordance is a critical component of patient-centered care, and further attention is needed to establish standards for measurement and reporting.
Collapse
Affiliation(s)
- Karen Winn
- MGH Institute of Health Professions, Boston, USA.
| | - Elissa Ozanne
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, USA
| | - Karen Sepucha
- Harvard Medical School, Boston, USA; Health Decision Sciences Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, USA
| |
Collapse
|
26
|
Dillworth J, Dickson VV, Mueller A, Shuluk J, Yoon HW, Capezuti E. Nurses' perspectives: hospitalized older patients and end-of-life decision-making. Nurs Crit Care 2015; 21:e1-e11. [PMID: 25892177 DOI: 10.1111/nicc.12125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/18/2014] [Accepted: 07/10/2014] [Indexed: 11/28/2022]
Abstract
AIMS To explore pressing issues identified by nurses caring for older patients in US NICHE (Nurses Improving Care for the Healthsystem Elders) hospitals, regarding palliative care and end-of-life (EOL) decision-making. Objectives are to (1) identify the most pressing palliative care and EOL decision-making issues and strategies to address them and (2) identify the association of nursing demographics (age, gender, race, education and experience), institutional/unit characteristics and these issues. BACKGROUND Critical care nurses have an integral role in supporting older patients and families faced with palliative care and EOL decision-making issues. Despite national imperatives to improve the quality of palliative care, patients continue to experience uncontrolled pain, inadequate communication, disregard of their wishes and life prolonging interventions. These contribute to increased hospitalizations and costs. Understanding the prevalent issues is needed to address patient needs at the end-of-life. DESIGN It is a mixed method study. METHODS A secondary analysis of the NICHE Geriatric Institutional Assessment Profile (GIAP) database (collected 1/08-9/13) was conducted using the sample of Critical Care RNs who provided comments regarding palliative care and EOL decision-making. Qualitative data were analyzed using Dedoose software. Data clusters and patterns of co-occurring codes were explored through an iterative analysis process. Themes were examined across nurse demographics, institutional and unit characteristics. RESULTS Comments specifically addressing issues regarding EOL decision-making were provided by 393 critical care nurses from 156 hospitals (x‾ age = 42·3 years, 51% BSN degree). Overarching theme was discordance in goals of care (prolonging life versus quality of life), ineffective physician-patient-family communication, lack of time and unrealistic expectations. CONCLUSIONS Nurses' descriptions highlight the need for increased communication, staff education and availability of palliative care services. RELEVANCE TO PRACTICE Palliative care and EOL decision-making will remain a nursing priority as people age and require increased care.
Collapse
Affiliation(s)
- Judy Dillworth
- New York University, College of Nursing, New York, NY, USA
| | | | - Anna Mueller
- New York University, College of Nursing, New York, NY, USA
| | - Joseph Shuluk
- New York University, College of Nursing, New York, NY, USA
| | - Hye W Yoon
- New York University, College of Nursing, New York, NY, USA
| | | |
Collapse
|
27
|
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
|
28
|
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]
|
29
|
Karppinen H, Laakkonen ML, Strandberg T, Tilvis R, Pitkälä K. Living wills and end-of-life care of older people suffering from cardiovascular diseases: A ten-year follow-up. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
30
|
Pasman HRW, Kaspers PJ, Deeg DJH, Onwuteaka-Philipsen BD. Preferences and Actual Treatment of Older Adults at the End of Life. A Mortality Follow-Back Study. J Am Geriatr Soc 2013; 61:1722-9. [DOI: 10.1111/jgs.12450] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H. Roeline W. Pasman
- Department of Public and Occupational Health; Expertise Center for Palliative Care; Amsterdam The Netherlands
| | - Pam J. Kaspers
- Department of Public and Occupational Health; Expertise Center for Palliative Care; Amsterdam The Netherlands
| | - Dorly J. H. Deeg
- Department of Epidemiology and Biostatistics; Longitudinal Aging Study Amsterdam VU University Medical Center; EMGO Institute for Health and Care Research; Amsterdam the Netherlands
| | | |
Collapse
|
31
|
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
|
32
|
Abstract
BACKGROUND Sex-related differences in end-of-life decisions (EOLD) are underresearched and unexplored. OBJECTIVES To investigate whether there are (1) differences in demographic and/or clinical characteristics between male and female decedents; (2) differences between men and women in the prevalence of EOLD with a possible or certain life-shortening effect; (3) differences in EOL decision making between men and women. METHODS In 2007, we performed a postmortem survey in Flanders, Belgium among physicians certifying a large representative sample (n=6927) of death certificates. Response rate was 58.4%. RESULTS Of patients with nonsudden death, women more often die in a care home than men (31.4% vs. 18.2%) who more often die at home (24.1% vs. 17.9%). Men tend to die more often from cancer than women (45.4% vs. 32.1%). Decisions to withhold or withdraw potentially life-prolonging treatment are more often made in women (28.0% vs. 22.8%, P=0.003); euthanasia and pain and symptoms treatment [alleviation of pain and symptoms (APS)] occur more often in men (3.6% vs. 2.1% euthanasia, P=0.023; 41.8% vs. 36.9% APS, P=0.012). These differences disappear after controlling for confounders. Bivariate associations were found between sex and EOL decision making. Some of them remained after controlling for confounders. CONCLUSIONS It is not the patient's sex in itself that determines the likelihood of an EOLD, but the different clinical profiles of men and women at the end of life. Although sex is not a determining factor in the prevalence of EOLD, it influences the decision-making process, indicating that there may be a difference in the way that male and female patients participate in EOL decision making.
Collapse
|
33
|
|
34
|
Affiliation(s)
- J E Morley
- Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO 63104, USA.
| |
Collapse
|
35
|
Rietjens JA, Deschepper R, Pasman R, Deliens L. Medical end-of-life decisions: Does its use differ in vulnerable patient groups? A systematic review and meta-analysis. Soc Sci Med 2012; 74:1282-7. [DOI: 10.1016/j.socscimed.2011.12.046] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 11/22/2011] [Accepted: 12/13/2011] [Indexed: 11/30/2022]
|
36
|
Ko E, Cho S, Bonilla M. Attitudes toward life-sustaining treatment: the role of race/ethnicity. Geriatr Nurs 2012; 33:341-9. [PMID: 22405033 DOI: 10.1016/j.gerinurse.2012.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 01/24/2012] [Accepted: 01/27/2012] [Indexed: 11/16/2022]
Abstract
This study explores attitudes regarding life-sustaining treatments between Korean American and Mexican American older adults. A cross sectional design was employed to survey 122 older adults residing in an urban area on the West Coast (64 Korean Americans and 58 Mexican Americans). Face to face interviews were conducted using a structured questionnaire. Results show that Mexican Americans as compared to Korean American older adults hold more favorable attitudes toward life-sustaining treatments. Participants who were male were more likely to have positive attitudes toward life-sustaining treatments than female. Findings emphasize the importance of culturally sensitive end-of-life care practices which consider cultural variations in life-sustaining treatment preferences.
Collapse
Affiliation(s)
- Eunjeong Ko
- San Diego State University School of Social Work, CA, USA
| | | | | |
Collapse
|
37
|
Teno JM, Mitchell SL, Kuo SK, Gozalo PL, Rhodes RL, Lima JC, Mor V. Decision-making and outcomes of feeding tube insertion: a five-state study. J Am Geriatr Soc 2011; 59:881-6. [PMID: 21539524 DOI: 10.1111/j.1532-5415.2011.03385.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine family member's perceptions of decision-making and outcomes of feeding tubes. DESIGN Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life. SETTING Nursing homes, hospitals, and assisted living facilities. PARTICIPANTS Respondents whose relative had died from dementia in five states with varying feeding tube use. MEASUREMENTS Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems. RESULTS Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not. CONCLUSION Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.
Collapse
Affiliation(s)
- Joan M Teno
- Health Services, Policy, and Practice, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | | | | | | | | | | | | |
Collapse
|
38
|
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]
|
39
|
Disparities Between Preferences and Practice for End-of-Life Care. J Am Med Dir Assoc 2010; 11:9-10. [DOI: 10.1016/j.jamda.2009.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 09/14/2009] [Indexed: 11/18/2022]
|